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On the face of it
A review of the organisational
structures surrounding the
practice of cosmetic surgery
On the face of it
A review of the organisational structures
surrounding the practice of cosmetic surgery
A report by the National Confidential Enquiry into
Patient Outcome and Death (2010)
Written by:
A P L Goodwin MB BS FRCA
NCEPOD Clinical Co-ordinator
I C Martin LLM FRCS FDSRCS
NCEPOD Clinical Co-ordinator
H Shotton PhD
Researcher
K Kelly BA (Hons) PGCert
Research Assistant
M Mason PhD
Chief Executive
The authors and Trustees of NCEPOD would particularly like to thank
the NCEPOD staff for their work in collecting and analysing the data
for this study:
Robert Alleway, Sabah Begg, Bryony Bull, Heather Freeth, Dolores
Jarman, Waqaar Majid, Eva Nwosu, Karen Protopapa and Neil Smith.
Contents
Acknowledgements 3
Foreword 4
Key findings 7
Recommendations 8
Introduction 9
1 Method and data returns 11
2 Advertising, consent and patient information 16
3 The structure and case mix of teams
providing cosmetic surgery 27
4 Postoperative follow up, policies, facilities and protocols 34
5 Patient records and clinical audit 45
Conclusion 50
References 52
Appendices 55
1 Glossary of terms and abbreviations 55
2 Web-listings used to identify sites providing cosmetic surgery 58
3 Corporate structure and role of NCEPOD 58
4 Supporting organisations 60
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Acknowledgements
This report, published by NCEPOD, could not have been achieved without the
support of a wide range of individuals who have contributed to this study.
The expert group who advised NCEPOD on what to assess during this study:
Jacqueline Cuming Director of Clinical Services, The Harley Medical Group
Mark Henley Consultant Plastic Surgeon - Chairman of the
Interface Group in Cosmetic Surgery for the
Joint Committee on Surgical Training and Director
of British Academy of Cosmetic Practice
Douglas Justins Consultant in Pain Management and Anaesthesia
and NCEPOD Trustee
Chris Khoo Consultant Plastic Surgeon - Council member of British
Association of Plastic, Reconstructive and Aesthetic
Surgeons (BAPRAS), Chair of the British Academy of
Cosmetic Practice and of the Royal College of Surgeons
of England Aesthetic Surgery Project Group
James Partridge Chief Executive of Changing Faces, lay representative
Jackie Row Director of Clinical Policy and Development,
Aspen Healthcare
Sally Taber Director of the Independent Healthcare Advisory Services
Martin Utley Clinical Operational Research Unit, UCL
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Foreword
There is nothing wrong with cosmetic surgery. People are in most instances objective published data and since
are and should be as free to pay for surgical treatment this published data must also be available to most of those
for what they see as physical imperfections or the less who work in the sites studied, the extent of the room for
attractive consequences of ageing as they should be free improvement that has been identified is remarkable.
to seek treatment of pain or significant disease. Much of
it may have little to do with the treatment of illness, but The description of the data returns in Chapter 1 warns
it is a service that meets a need that people experience. the reader of the choppy waters that lie ahead. Ignore
Awareness of this point has developed in the 20 years the 212 sites that usually participate in our work and
since some citizens of Oregon provoked a public outcry concentrate on the 619 that do not: 11.5%, that is 71 of
by choosing cosmetic breast surgery before treatment them are clinics that had ceased to exist between being
of open thigh fracture when they were consulted in an identified and being approached. Of the remaining 548,
attempt to create a transparent set of healthcare priorities.1 68% (371) either did not answer or refused to take part.
This suggests that they are unaware of their obligation to
However, we should recognise that those who meet this take part in the work of the confidential enquiries or take
need are responding to a distinctive demand that poses an nonchalant attitude to such obligations.
its own problems because the tolerance of physical
imperfections is subjective. Furthermore, because a large In other reports low participation rates may be
proportion of cosmetic surgery is not available on the NHS, understood in the context of the difficulty of finding and
commercial interests hold a decisive sway. Most other copying bulky sets of clinical notes. Neither applies here.
private practice is a supplement to NHS practice, carried Of particular concern to NCEPOD is whether the 32%
out in their spare time by surgeons doing operations that who responded are likely to be more conscientiously
they have been trained to do in the NHS. This means organised than their less co-operative peers. As with
that the regulation of this pattern of care raises different previous studies, one wonders whether this report may
problems from many other aspects of medicine. give a misleadingly reassuring impression of what is really
happening in this market place. If so, it only adds force to
NCEPOD usually studies a cohort of cases looking for the findings and recommendations of the authors.
events that show room for improvement in the views of
our specialist advisors. We always include criticisms When we come to the meat of the Study, I think the
of organisational factors where these are relevant; fundamental weakness of the pattern of care that is
however this study is unusual in being concerned described seems to be that it is often far too dispersed
entirely with organisational matters. We have not studied and disorganised. Throughout medicine it is now
individual cases nor criticised what has happened to becoming a commonly accepted dogma that performing
a single patient. We have not considered the extent of procedures occasionally is unacceptable practice.
complications, plainly unacceptable results or patients Cardiac surgeons were the first to learn painfully in the
who are dissatisfied by results that their surgeons deem wake of the Bristol scandal of the ‘90’s that small centres
to be acceptable. This report describes the facilities and are not beautiful. Since then most other specialties have
methods that the clinics bring to their work. The yardsticks introduced criteria that acknowledge the same point.
against which the authors have measured their findings For example, in Scoping our Practice (2004), NCEPOD
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reported that performing 20 procedures a year was as regulation and surgical competence. As the definition
insufficient to maintain an individual’s endoscopy skills. In of an NHS hospital becomes looser, the obligation on
those areas of medicine where the results of inadequate the private sector to pull its weight in training is likely to
skill are less starkly evident we have learned the same become more intense. This shoe is pinching here first
lessons, albeit more slowly. because it is only in the private sector that procedure-
specific training can be provided where procedures are
Yet, in cosmetic surgery we find numerous teams who not carried out in NHS hospitals.
are apparently prepared to “have a go” at procedures
that they rarely perform. Unsurprisingly but worryingly, A third issue is patient selection. The patrons of these
it is the more difficult procedures that are undertaken premises include a proportion of patients who may have
most rarely. Thus, we find from Table19 on page 28 that unrealistic aspirations and more deep-seated problems.
there are 31 places doing the relatively common and So it is dispiriting to see that the majority of places do
straightforward breast augmentations who do them less not include a psychological assessment as part of the
than 10 times a year. This is occasional surgery by any routine initial consultation,6 and where a psychological
standards. Yet more troublingly, when we look at breast assessment is carried out, at only 4% of sites is it normal
reduction, which is relatively complex surgery, 79% of for a patient to see a Clinical Psychologist.7
centres undertaking it do so on less than 20 occasions a
year. There are 84 centres doing between 1 and 10 breast
reductions in a year. No doubt some of the Consultants What is to be done?
are working in the private sector in their spare time,
so that one member of the team may be doing these It is trite to say that the first line of protection must be the
procedures more regularly in the NHS; however it is not patients themselves. In seeking out this sort of treatment
clear where there are any controls. Who in the private they are asserting the personal right with which I began.
clinic knows what the surgeons are doing elsewhere? In doing so patients should interrogate their surgeons and
One wonders how the team as a whole can maintain their their teams and we hope this report may help them to
skills to undertake these procedures and what they are identify the questions they need to ask. I suggest that if
doing the rest of the time. the glossy brochures do not condescend to the detailed
description of issues identified by our authors, patients
The second casualty seems to be safety. As a consequence should be encouraged by this report to ask and I draw
of this disparate provision our authors found an alarming attention to the list of questions our authors have prepared
lack of equipment available in theatre,2 in proper recovery which are available on our website. If the team are shy
facilities,3 in HDU facilities4 and in out of hours surgical about saying how often the procedure being contemplated
cover.5 In small centres the unit cost of providing this sort is done by the surgeon at the centre, or there is not
of back-up becomes prohibitively expensive. readily available detailed information about the recovery
arrangements, resuscitation facilities and out of hours
Another casualty seems to be surgical training. It is cover, then a patient may be in the wrong place.
available in only 16% of these sites (page 31). In one This report may also encourage patients to consult their
sense this may be just as well: what sort of training general practitioners before approaching such a specialist.
can be offered in a centre that performs most of its
procedures less than once a month? However, there is Yet we must acknowledge that the essence of modern
also no doubt that if this work were concentrated in fewer regulation is to protect those who are too trusting and fail
centres where there was a proper throughput of work, we to ask questions. A consumer of medical services should
could expect to see an improvement in training as well not have to be an auditor. Just as we do not demand to
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check the hygiene in the kitchen and fridges before we sit On behalf of NCEPOD I am grateful to those who have
down to eat in a strange restaurant, patients are entitled to made this study possible. The expert group who advised
suppose that clinics offering surgery in the High Street are NCEPOD on what to assess and the questions to ask
properly regulated by those who are paid to do so. Thus included a number of senior insiders. We had two
the patients’ common sense must here be fortified by an distinguished Consultant Plastic Surgeons, Chris Khoo
enhanced role for the regulators. and Mark Henley; also there were four senior managers:
Sally Taber, the Director of the Independent Healthcare
This is not a report that demands the expenditure of Advisory Services; Jacqueline Cuming, from the Harley
money or primary legislation by central government, in Medical Group; Jackie Row from Aspen Healthcare and
the first instance at least. The remedy for these problems James Partridge, the Chief Executive of Changing Faces.
lies principally in the hands of the clinics and the Douglas Justins who is an NCEPOD Trustee as well as
profession and those who regulate them both. being a senior anaesthetist also helped to devise the
study. Martin Utley from the Clinical Operational Research
First and foremost this report reveals a challenge for the Unit at UCL, who is also a member of our Steering Group
Care Quality Commission (CQC). This part of the CQC’s kept them all on the mathematically straight and narrow.
inheritance has here been identified as a problematic
cottage industry pattern of laissez-faire provision. The The nine researchers who did most of the work in
CQC should insist that those it regulates are properly collecting material were led by Hannah Shotton and
equipped and adhere to appropriate standards. Kathryn Kelly who were also authors with two of our
Clinical Co-ordinators, Alex Goodwin and Ian Martin.
The GMC should give clearer guidance to doctors The contents of the report were carefully considered
as to their responsibilities when caring for a cohort and discussed by the whole Steering Group of our
of patients, some of whom may be acting unwisely. stakeholders at our meeting in February and since then
Doctors performing these procedures should have drafts of the report have been circulated and reviewed by
procedure-specific training and the professional all involved on at least two further occasions. We believe
regulator should insist that they adhere to a code of it is this methodology of guidance by knowledgeable
conduct that is responsive to the particular needs of insiders and comment from a broad group of questioning
their patients and the environment in which they work. professionals that make our studies robust.
The GMC book “Consent: Patients and Doctors Making
Decisions Together” contains guidance about patients
who lack legal capacity, but not about those who may
be acting unwisely in seeking treatment that may not
be in their best interest. Such guidance in defining the
characteristics of the acceptable would be invaluable to
doctors as well as patients. Good doctors benefit from
guidance on which they can rely to demarcate the limits Bertie Leigh
of what is appropriate, when it is not always obvious. Chair of NCEPOD
In the meantime I hope this report will empower patients 1. Klein Rudolf: On the Oregon Trail 1991; BMJ 302;1-2,
by putting in their hands the information that will enable 2. see table 33 page 39, 3. see table 36 page 41
them to make more informed choices about where and to 4. see table 39 page 42, 5. see table 24 page 32
whom they should entrust themselves. 6. see table 14 page 22, 7. see figure 3 page 23
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Key Findings
• Many cosmetic surgery sites are offering a menu
of procedures some of which were only performed
infrequently
• All the sites returning a questionnaire were either
registered with the Care Quality Commission
(or equivalent regulatory body in the devolved
administrations) or were not required to be under
current regulations
• 348/361 (96%) sites indicated that patient outcomes
were monitored
• Routine psychological evaluation prior to cosmetic
surgery was carried out in 119/335 (35%) of
sites, and in only 4/100 (4%) of those sites were
assessments routinely performed by a clinical
psychologist
• A two-stage (deferred) consent process was not
performed in 91/282 (32%) of sites
• 46/138 (33%) of independent hospitals with inpatient
beds providing cosmetic surgery did not have a
cosmetic surgery consultant rota for anaesthesia
• 67/220 (30%) of sites performing cosmetic surgery
did not have a Level 2 care unit
• Only 101/228 (44%) of operating theatres were fully
equipped to undertake cosmetic surgery
• 39/216 (18%) of sites performing cosmetic surgery
had no emergency re-admission policy
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Recommendations
• Regulatory bodies, such as the Care Quality • Cosmetic surgical practice should be subject to
Commission, should more closely monitor the the same level of regulation as any other branch of
adherence to national requirements for audit surgery.
and scrutiny of sites under licence. The scope of
regulation should include all sites including those • Independent health care providers should only allow
only undertaking consultation. practising privileges to those cosmetic surgeons
who can demonstrate that they have achieved and
• National professional cosmetic surgery bodies are able to maintain competence in the procedures
should issue guidelines as to the training, level of which they offer.
knowledge and experience required for a cosmetic
surgeon to achieve and maintain competence in the • Defence organisations might consider whether
procedures which he or she undertakes. it is appropriate to indemnify practitioners who
are unable to demonstrate the attainment and
• Those considering having cosmetic surgery should maintenance of appropriate levels of competence
be advised to check Care Quality Commission for the procedures which they perform.
registration of any site they attend.
• Psychological assessment is an important part
• Guidelines for the equipping of theatres and the peri- of any patient’s cosmetic surgery episode and
operative monitoring of patients must be followed. should be routine. This part of a patient’s care
must be delivered by those adequately trained and
• Good practice demands a two-stage consent reliable psychological assessment tools need to be
process for those undergoing cosmetic surgery. developed.
• A national cosmetic surgery outcome database • Regulation should be introduced to prevent the use
should be considered. of financial inducements to influence the process of
informed consent.
• More formal training programmes must become
established, and like any other surgical training,
these should be subject to rigorous assessment
of competence, which should lead to a certificate
attesting to the surgeon’s level of competence
in specified procedures. The present reliance on
inclusion on the specialist register does not give any
assurance that a surgeon has received adequate
training in cosmetic surgery.
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Introduction
The remit of NCEPOD covers not only practice within the However, the lack of a cosmetic surgery specialty makes
NHS but also within the independent sector. Cosmetic regulation difficult.
surgery is perhaps the most controversial area of
independent practice and certainly one which is a major According to The Care Standards Act, all independent
growth “industry”. Cosmetic surgery has become more clinics and hospitals that provide cosmetic surgery in
available, socially acceptable and financially achievable England must be registered and inspected by the CQC. In
for a wider cross section of society. In 2008 the British Wales they must register with the Healthcare Inspectorate
Association of Aesthetic Plastic Surgeons (BAAPS) of Wales (HIW) and in Northern Ireland, with the
reported a 275% increase in breast augmentation Registration and Quality Improvement Authority (RQIA).2
operations since 2002.1 Cosmetic surgery differs in one
major respect from other types of surgery in that it is In 2004, the Healthcare Commission (now the CQC)
undertaken as a life style choice as opposed to surgery carried out an extensive review of the provision, safety
to cure or ameliorate a disease. Furthermore, patients are and quality of cosmetic surgery practice in England
effectively entering into a contract by paying a surgeon to and presented the findings to the Chief Medical Officer
produce an agreed result, be that the shape of the nose in the 2005 report “Provision of cosmetic surgery in
or the size of the breasts they desire, or to combat the England: Report for the Chief Medical Officer Sir Liam
perceived undesirable effects of ageing. Donaldson”.3 In the same year, the Department of Health
took the Healthcare Commission report into consideration
There is a lack of a definition of cosmetic surgery which and published “Expert Group Report on the Regulation of
adds to the misinformation and confusion surrounding Cosmetic Surgery to the Chief Medical Officer”.4 These
the practice. The term is often used interchangeably with two studies reviewed regulated cosmetic procedures
‘plastic surgery’ or ‘aesthetic surgery’. as well as reviewing staff training and development,
consumer information, patient records and clinical audit.
The lack of definition in part stems from the fact
that it is not an official surgical specialty in its own Both reports indicated a need for better information
right, but involves practitioners of plastic surgery, and regulation of the practice of cosmetic surgery and
oral and maxillofacial surgery, ENT, ophthalmology several recommendations were made to the government.
and dermatology among others. The lack of defined Since their publication there has been a review of the
specialisation in this country has implications for ensuring national minimum standards5 as well as the publication of
that surgical procedures are carried out by appropriately guidelines for good medical practice in cosmetic surgery,
qualified surgeons. According to The Care Standards by the Independent Healthcare Advisory Services, in
Act, 20002 practitioners performing cosmetic surgical 2006.6 The NHS Modernisation Agency also looked
procedures in the independent sector must have at plastic, reconstructive and aesthetic surgery within
undergone basic medical training and (those registered the NHS and provided recommendations for good
after 2002) must be on the specialist register of the GMC. practice, which involved a more coordinated approach
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to delivery of optimum service within a local stakeholder information regarding structure, function and locations
commissioning group framework.7 of cosmetic practice. This report does not include those
aesthetic or cosmetic procedures undertaken to manage
In this study NCEPOD aimed to investigate key areas of disease processes. NCEPOD considers this study to be
variation in the practice of cosmetic surgery in the NHS a first step in identifying the variations in organisation and
and the independent sector. The study has reviewed basic practice of cosmetic surgery.
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1 – Method and Data returns
Study aim Expert group
The aim of this study was to investigate variations in A multidisciplinary expert group, representing
organisational structures surrounding the practice of professional cosmetic surgery providers and the Industry,
cosmetic surgery in England, Scotland, Wales, Northern contributed to the design of the questionnaire and
Ireland and the Offshore Islands. reviewed the results of the analysis of the data returned.
This composition of the Expert group is outlined on
Four areas were studied, in order to obtain baseline page 3.
information which should help inform and direct
subsequent more detailed investigation of practice. Pilot study
These areas were:
A pilot study was performed to test the questionnaire
1 Advertising, consent and patient information for clarity and validity. Twenty four sites were contacted
2 The structure and case mix of teams providing (seven independent hospitals, Fourteen clinics and three
cosmetic surgery NHS hospitals). Six questionnaires were returned and
3 Postoperative follow up, policies, facilities and following this the questionnaire was finalised.
protocols
4 Patient records and clinical audit
Main study
Definition of cosmetic surgery Site identification
Cosmetic surgery was defined for the purpose of this All sites identified in England, Wales, Northern Ireland,
study as: the Isle of Man and the Channel Islands that perform
“Operations that revise or change the appearance, cosmetic surgical procedures or carry out consultations
colour, texture, structure or position of the bodily for cosmetic surgery were included in the study.
features to achieve what patients perceive to be Additionally, for this study, independent hospitals and
more desirable”8 clinics in Scotland were included with the agreement of
the Scottish Audit for Surgical Mortality (SASM).
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Data acquisition (RCGP) it became clear that obtaining email addresses of
A questionnaire was sent to the following sites in which UK GPs, in order to carry out an initial mailing would not
cosmetic surgery was performed or organised: be possible. Therefore GP sites were only included if they
were listed on the CQC register for independent health
1 Independent sector hospitals in England, Wales and care providers or if they advertised cosmetic surgical
Northern Ireland procedures in the included web listings.
2 NHS hospitals in England, Wales and Northern
Ireland During the full study 1093 questionnaires were sent out
3 Independent sector hospitals in Scotland to cosmetic surgery sites between July and September
4 Members of BAAPS who see patients at sites other 2009. Reminder letters were sent after six weeks then
than hospitals already covered again a further four weeks later and a final reminder in
5 IHAS members: National multi-site providers of December on behalf of NCEPOD and the study expert
cosmetic surgery group members. Study researchers also carried out
6 Independent hospitals, clinics and non-surgical telephone and email chasing of questionnaires with the
cosmetic treatment centres registered with the CQC, final deadline for return being the 15th January 2010.
The Health Inspectorate of Wales (HIW) or
The Regulation and Quality Improvement Authority
of Northern Ireland (RQIA) Data analysis
7 Clinics and treatment centres listed on Yell.com and
other web listings listed as providers of cosmetic The data from the questionnaire were electronically
surgery (see Appendix 2 for the complete list) scanned into a preset database. Prior to analysis, the
data were cleaned to ensure that there were no duplicate
Sites were excluded if they were found to be non- records and that erroneous data had not been entered
cosmetic sites, non-surgical sites or sites providing during scanning. Fields containing spurious data that
only reconstructive surgery as part of the management could not be validated were removed.
of disease processes. As this study was at the
organisational level, data were collected from each Following cleaning, the data were analysed using
individual site (a site being administratively and/or descriptive statistics using Microsoft Excel. The results
geographically separate from all others). Therefore, each were reviewed by the study Expert Group and the
individual clinic belonging to a large multi-site provider NCEPOD Steering Group prior to publication.
was treated separately. Likewise, to avoid repetition of
organisational data, data from cosmetic surgeons were
only included if they carried out consultations at a site Data returns
separate to the hospital where the surgery was performed
and they were only questioned on the consultation Of the 1093 questionnaires sent out, 291 were sent to
aspects of their practice. sites which already participate in the work of NCEPOD
(NHS and independent hospitals). Seventy nine of these
On the basis of anecdotal evidence that cosmetic surgery sites were excluded as they undertook reconstructive
was being carried out in some general practice (GP) surgery only, leaving 212 sites. Of these 185 (87%)
surgeries, data collection was attemped from this group. returned questionnaires and 26 failed to return their
However, having approached individual primary care questionnaires. One questionnaire was sent but did not
trusts and the Royal College of General Practitioners arrive.
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A further 802 sites were identified which did not questionnaire was made clear, there was substantial
participate in the core work of NCEPOD. Sites were difficulty in obtaining data from sites unfamiliar with
excluded if they were non-surgical cosmetic (69), non- NCEPOD. This may simply reflect a lack of familiarity
cosmetic (82), other e.g. duplication (31) or reconstructive or could be interpreted as a general unwillingness to
(1). Therefore 619 sites were assumed to be eligible to participate in self review. Audit, be it personal, local or
participate. Of these, further verification confirmed that 71 national is an integral part of maintaining high standards
sites no longer existed, leaving 548 currently practicing. of patient care. This raises concern for those sites that
Of these sites 176 (32%) returned their questionnaires, were unwilling to participate. All patients should enquire
13 refused to complete the questionnaire and 358 failed as to the CQC registration and last inspection of the
to answer and return the questionnaire despite repeated site they are considering attending. The CQC needs to
reminders. Overall, 361/760 sites returned questionnaires ensure that all licensed sites demonstrate participation in
(see figure 1). With 11.5% of companies listed but no national audit.
longer trading, there appeared to be a substantial turn-
over of companies providing cosmetic surgery. The HIW and RQIA appeared to have similar
arrangements for registration of independent providers
The Care Standards Act and IHAS: Good Medical of cosmetic surgery as the CQC in England,10,11 however
Practice in Cosmetic Surgery/Procedures, requires all in Scotland, it appeared that currently only independent
independent practitioners, clinics and hospitals to be hospitals are obliged to register with the Scottish
registered with the CQC.2,6 Part of this registration Commission for the Regulation of care.12 Small clinics
requires that the sites participate in national audit are not required to be registered even if they carry out
which includes the work of the National Confidential cosmetic surgery on site.
Enquiries.9 While the requirement to complete the
TOTAL QUESTIONAIRES
SENT - 1093
ELIGIBLE TO PARTICIPATE EXCLUDED
SITES - 760 333
RETURNED NOT RETURNED
361 (47.5%) 399 (52.5%)
Figure 1. Data returns
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The denominator changes throughout this report. This Of those included 324/361 sites providing cosmetic
is because there are sites which have a differing level of surgery lie outside the National Health Service.
involvement in the care of cosmetic surgery patients and The structure of the cosmetic surgery industry is
which completed different sections of the questionnaire. complicated. There are several different types of provider
There are sites that act as an initial point of contact for of cosmetic surgery who are responsible for different
prospective patients, brokering services that have no parts of the patient pathway, which may add to the
further involvement in the patient pathway. There are difficulty in regulation and determining who has ultimate
sites where only initial consultations are performed but responsibility for the patient’s welfare. The majority
no surgery is carried out on site. There are sites that only of sites returning questionnaires were independent
carry out surgery and sites that are involved with every hospitals in patient (IP) and out patient/day-case (OP),
step of the patient pathway. The total number of sites that most of which who oversee the patient throughout
returned questionnaires was 361 of which 350 sites acted the whole process from the initial consultation to the
as the initial point of contact for patients. Of these 344 postoperative follow-up appointment, allowing a degree
sites carried out initial consultations and 228 sites carried of continuity. Questionnaires were received from
out cosmetic surgery on site. 100 non-surgical treatment centres that only perform
non-surgical cosmetic treatments on site, but where
consultations for cosmetic surgery take place. A further
Description of sites participating 37 questionnaires were received from NHS hospitals
that carry out a small number of cosmetic surgical
The type of site from which a questionnaire was returned procedures for reasons other than to correct a pathology
is shown in Table 1. or for reconstructive purposes. Questionnaires were
received from 21 independent surgeons who see patients
Table 1. Type of site that returned a questionnaire at sites other than hospitals already covered. Large (>3
Description of site Total % clinicians employed) and small (<3 clinicians employed)
independent clinics made up a smaller proportion of
Independent Hospital - in patient 159 44.0
the sample (large clinics = 2/361, small clinics = 8/361)
Non-surgical Treatment Centre 100 27.7 as did the brokers for UK (3/361) and abroad (4/361).
NHS Hospital 37 10.2 One questionnaire was returned from a GP surgery.
Cosmetic Surgeon 21 5.8 The description of 14 ‘other’ sites did not come under
any of the categories listed on the questionnaire. These
Other 14 3.9
identified themselves as: Private patient facility within
Independent Hospital - out patient 12 3.3 NHS hospital (six), a group of surgeons practicing in more
Small clinic (<3 clinicians) 8 2.2 than one hospital (two),
non-cosmetic surgeon (one) ambulatory surgical/
Referral Service (abroad) 4 1.1
diagnostic unit (two) independent sector treatment
Referral Service (UK) 3 <1 centre (ISTC) carrying out consultations and day
Clinic (>3 clinicians) 2 <1 case surgery for some procedures on site but other
GP 1 <1 procedures elsewhere (three).
Total 361
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Registration with a Regulatory Body
All sites carrying out cosmetic surgery should be
registered with CQC.9 (Table 2)
Table 2. Type of site registered with the CQC
Registered with the CQC
Description of site Yes % No % Subtotal NA Unanswered Total
Independent Hospital - in patient 152 98.7 2 1.3 154 3 2 159
Non-surgical Treatment Centre 87 87.9 12 12.1 99 1 0 100
NHS Hospital 25 89.3 3 10.7 28 4 5 37
Individual Cosmetic Surgeon 10 66.7 5 33.3 15 6 0 21
Other 8 80.0 2 20.0 10 3 1 14
Independent Hospital - out patient 12 100.0 0 0.0 12 0 0 12
Small Clinic (<3 clinicians) 8 100.0 0 0.0 8 0 0 8
Referral Service (abroad) 0 0.0 1 100.0 1 2 1 4
Referral Service (UK) 0 0.0 0 0.0 0 3 0 3
Clinic (>3 clinicians) 2 100.0 0 0.0 2 0 0 2
GP 1 100.0 0 0.0 1 0 0 1
Total 305 86.1 25 7.7 330 22 9 361
Table 2 shows that responses from twenty five sites For sites that answered ‘Not Applicable’, similar results
stated that they were not registered with the CQC. When were found: thirteen sites did not perform any surgery on
these were looked at in more detail, it was found that site and six were regulated by regulatory bodies within
eighteen sites only carried out consultations on site the devolved administrations, with the exception of one
and therefore were not under the present regulations clinic in Scotland that is currently not required to be
required to be registered. A further seven sites were registered. All the sites that failed to answer the question
based in Wales, Northern Ireland or Scotland and were were either registered with a regulatory body or were not
registered with the equivalent regulatory bodies in the required to be registered.
devolved administrations (i.e. HIW, the RQIA and the
SCRC, respectively).
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AN – A
2
2 – Advertising, consent and patient information
Advertising the services a doctor provides must be verifiable, truthful
and that they must not make claims that they are any
The advertising of medical services is constrained better than any other practitioner18. Claims should not
by codes of conduct laid down by the Committee of be made about the quality or outcomes of services in
Advertising Practice (CAP)13 who are overseen by the any information provided to patients. Advertising must
Advertising Standards Authority (ASA)14. The BAAPS and not offer guarantees of cures, nor exploit patients’
the IHAS have also produced consensual agreement on vulnerability or lack of medical knowledge. Equally a
the standards employed in the advertising of cosmetic patient’s vulnerability or lack of medical knowledge must
surgery procedures.15,16,17 not be exploited when making charges for treatment or
services.6
Marketing materials must be drafted and designed
to safeguard patients from unrealistic expectations. When asked about advertising, 303/342 (88.6%) sites
Advertisements should depict real life. Unjustifiable stated that they advertised their services (Table 3).
claims should not be made and discounts or financial
incentives must not be offered. Good medical practice
states that any information that appears in print about
Table 3. Type of site and advertising of services
Advertise
Description of site Yes % No % Subtotal Unanswered / Total
Not applicable
Independent Hospital - in patient 147 95.5 7 4.5 154 0 154
Independent Hospital - out patient 12 100.0 0 0.0 12 0 12
NHS Hospital 0 0.0 27 100.0 27 6 33
Small Clinic (< 3 clinicians) 8 100.0 0 0.0 8 0 8
Non-surgical Treatment Centre 98 100.0 0 0.0 98 2 100
Individual cosmetic surgeon 18 85.7 3 14.3 21 0 21
GP 1 100.0 0 0.0 1 0 1
Referral service (UK) 3 100.0 0 0.0 3 0 3
Referral Service (abroad) 4 100.0 0 0.0 4 0 4
Other 12 85.7 2 14.3 14 0 14
Total 303 88.6 39 11.4 342 8 350
16
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The two sites that did not advertise and described
themselves under the category ‘other’ were one private
site within an NHS hospital and one group of surgeons
practicing at more than one hospital.
Methods used for advertising are shown in Figure 2.
Multiple answers may have been provided by each site
(from a maximum of 342 sites).
Number of sites
300
250
200
150
100
50
0
s
or
ts
y
g
y
g
ts
rt
ia
s
g
s
s
r
er
or
te
ad
ad
tin
lin
lin
po
ed
as
le
pe
do
si
rg
ct
ai
ph
ai
lis
ns
dc
tm
up
e
a
ut
su
re
m
em
ng
lin
sp
eb
m
tra
O
oa
p-
di
en
on
ct
ki
Pa
ic
ew
w
lk
Po
Br
ss
or
re
ic
et
bi
Bu
er
er
N
bl
tw
Di
sm
ne
Am
th
th
Pu
ne
si
O
co
O
Bu
al
g-
ci
in
So
t
lis
eb
W
Advertising method
Figure 2. Methods of advertising utilised by sites providing or organising cosmetic surgery
The group using broadcast media (radio and television) Table 4. Type of site using broadcast media
were divided into the groups shown in Table 4. This group Description of site Total %
fell entirely outside the NHS.
Independent Hospital - in patient 58 41.7
Independent Hospital - out patient 2 1.4
Small Clinic (<3 clinicians) 2 1.4
Non-surgical Treatment Centre 68 48.9
Individual Cosmetic Surgeon 2 1.4
Referral Service (abroad) 1 <1
Other 6 4.3
Total 139
17
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2
The sites using social networking sites and pop-up The use of electronic media to promote and advertise
advertisements and bulk emailing, which fall outside of cosmetic surgery by its nature much harder to regulate.
any formal regulatory process were in the groups shown Bulk emailing, pop-ups, social networking sites and web
in Tables 5 to 7. based advertisements may be more likely to influence
groups of patients more vulnerable to suggestion.
Such is the concern over the effects of advertising
Table 5. Type of social networking websites used on patients that a number of countries have recently
Description of site Total tightened up the legislation surrounding cosmetic surgery
advertising19-21 and in France, since 2005, it has been
Independent Hospital - in patient 18
banned completely in every format including web based
Independent Hospital - out patient 1 publicity.22
Small Clinic (<3 clinicians) 2
Non-surgical Treatment Centre 38 In the UK the guidelines issued by the BAAPS and the
IHAS form the foundations of a code of conduct, which
Referral Service (abroad) 2
is not necessarily enforceable by law. Therefore, only if
Other 1 the more general CAP codes of practice are contravened
Total 62 can advertisers be penalised by the ASA. However,
misleading advertisements may also come under the
jurisdiction of trading standards officers.
Table 6. Type of site using pop-up advertisements
Description of site Total Sites that admitted to promoting special offers are shown
in Table 8. Of the sites that answered the question
Independent Hospital - in patient 12
77/295 (26%) admitted to promoting special offers.
Independent Hospital - out patient 1 Financial offers are permitted according to the IHAS
Small Clinic (<3 clinicians) 2 guidelines as long as they are not advertised in the public
Non-surgical Treatment Centre 23 domain.17 Such offers, when time is limited, may put
undue pressure on patients to have an operation in haste
Total 38
for which they may be inadequately prepared.
Table 7. Type of site using bulk emailing In addition to the questions on advertising in the
Description of site Total questionnaire, a sample of advertisements from
newspapers and magazines were assessed as to whether
Independent Hospital - in patient 10
they conform to the guidelines produced by the IHAS and
NHS Hospital 2 the BAAPS.
Small Clinic (<3 clinicians) 2
Non-surgical Treatment Centre 52 Every advertisement for cosmetic surgery in the printed
published media was collected over the course of one
Individual Cosmetic Surgeon 1
year (summer 2009-summer 2010). From newspapers
Other 2 and magazines over 150 advertisements were collected.
Total 69 However, having removed duplicates, the final sample
consisted of only 39 advertisements. Nevertheless
18
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Table 8. Site type and promotion of special offers
Special offers promoted
Description of site Yes % No % Subtotal NA Unanswered Total
Independent Hospital - in patient 32 22.2 112 77.8 144 7 3 154
Independent Hospital - out patient 1 8.3 11 91.7 12 0 0 12
NHS Hospital 0 0.0 16 100.0 16 17 0 33
Small Clinic (<3 clinicians) 1 14.3 6 85.7 7 1 0 8
Non-surgical Treatment Centre 37 49.3 38 50.7 75 1 24 100
Individual Cosmetic Surgeon 2 9.5 19 90.5 21 0 0 21
GP 0 0.0 0 0.0 0 0 1 1
Referral Service (UK) 0 0.0 3 100.0 3 0 0 3
Referral Service (abroad) 2 50.0 2 50.0 4 0 0 4
Other 2 15.4 11 84.6 13 1 0 14
Total 77 26.1 218 73.9 295 27 28 350
these 39 advertisements were objectively assessed as It was found that only a minority of sites 5/39 displayed
to whether they advertised prices and special offers the CQC logo (Table11) and only 2/39 displayed
(discouraged by IHAS and BAAPS guidelines) and their CQC registration number (data not shown).
whether they displayed the CQC logo and their CQC The CQC now specifically prohibits the use of their
registration number. logo by institutions registered with them.23 Patients
need to easily recognise those sites with appropriate
The majority of sites did not advertise discounts in line registration. The removal of the CQC logo from
with the published guidelines. However, there were two material produced by those providers practicing at an
advertisements that clearly did so (Table 9). appropriate level of regulation is a backward step. It is
unclear as to whether the display of a CQC registration
Similarly, most advertisements assessed did not display number is also prohibited. The importance of raising
prices in accordance with the guidelines, however, there awareness amongst potential cosmetic surgery patients
were 8/39 advertisements that clearly displayed the of the necessity of checking provider’s credentials
price of cosmetic surgical procedures, in violation of the with respect to CQC registration has been highlighted
guidelines (Table 10). elsewhere in the report.
Table 9. Number of advertisements that displayed discounts Table 10. Number of advertisements that displayed prices
Discounts advertised Total Prices displayed Total
Yes 2 Yes 8
No 36 No 30
NA 1 NA 1
Total 39 Total 39
19
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Table 11. Number of advertisements that displayed logo patients have realistic expectations of the effect that
CQC logo displayed Total the procedure will have. Information may be delivered
in several different forms. Table 12 shows how potential
Yes 5
patients were provided with information.
No 30
NA 4 Information is central to a patient’s ability to make a
Total 39 decision about their health care. Patients need access
to impartial, high quality information so they can make
informed decisions. In the National ‘Building on the Best
Patient information Choice’ consultation in 2003 nearly 90% of respondents
In order that a patient might give informed consent he said that in order to make choices about their health and
or she needs to be fully informed about the risks and health care they needed the right information at the right
benefits of the procedure. In cosmetic surgery, the time with the support they need to use it.24 With poor
consenting process is also important to ensure that information patients cannot make effective choices.24
Table 12. Methods of informing patients
or
e
o
ct
rs
nf
er on
do
nu
ri
VD
so
rg fo
et
n:
n:
/D
y
su in
vi
io
io
afl
D
ad
ss
ss
ic H
le
C
et D
ed
cu
cu
al
fo
fo
o
er
ic
is
is
in
in
sm r t
in
ld
ld
w
co efe
nt
nt
cl
ns
ba
ba
er
tie
tie
al
R
on
na
th
r
r
t
Pa
Pa
Ve
Ve
To
Description of site
O
U
N
Independent Hospital -
in patient 150 8 154 115 16 37 13 0 154
Non-surgical Treatment
Centre 90 28 90 59 51 8 3 7 100
NHS Hospital 26 2 34 20 1 5 5 0 33
Independent Hospital -
out patient 11 1 12 5 0 2 3 0 12
Small Clinic (<3 clinicians) 8 1 8 4 2 3 2 0 8
Referral Service (UK) 3 0 3 1 3 0 0 0 3
Referral Service (abroad) 3 1 2 0 7 1 1 0 4
Individual Cosmetic
Surgeon 16 0 21 7 1 7 4 0 21
Other 11 0 14 7 1 1 1 0 14
GP 1 0 1 0 0 0 0 0 1
Total 319 41 339 218 82 64 32 7 350
(Multiple answers may have been given, total = 350 sites)
20
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Specifically a patient needs information on their own should have access to independent information about
condition, care options and possible outcomes. When cosmetic surgery.3 It is also recommended that patients
they have good access to these, patients are better should have access to written information in support
equipped to give valid informed consent. of appropriate verbal information. There should be no
reason why this is not provided for cosmetic surgery,
Patients should have access to accurate, high quality, but in a number of sites, both within the NHS and
comprehensive information delivered in the way they independent sector, written information was not available.
want and can understand. They should have their
personal needs considered and discussed at every The IHAS recommend that the initial consultation be
contact with a surgeon, receiving as much support as carried out by a surgeon or registered practitioner, so that
they want to access and understand information. They unsuitable patients can be excluded at an early stage.25
should be allowed to ask questions and be involved In 191/337 (56.7%) of sites, the initial consultation was
as far as they wish in making decisions about the always and only conducted by a consultant surgeon
benefits and risks of cosmetic surgery. Only 64/350 (Table 13). Whilst the vast majority of sites that answered
sites referred patients to the Department of Health this question complied with this standard, there was one
independent information on cosmetic surgery (Table site where patients undergo initial consultations with a
12). It has been previously recommended that patients non-medical member of staff.
Table 13. Staff member conducting the initial consultation
Who conducted the consultation Total %
Always/only consultant surgeon 191 56.7
Consultant surgeon or other doctor or nurse 96 28.5
Consultant surgeon or other personnel including non-medical staff 33 9.8
Consultant surgeon or psychologist 1 <1
Non-consultant specialist (no consultant) 3 <1
Specialist doctor/nurse (no consultant) 1 <1
GP 1 <1
Specialist nurse practioner (no consultant) 1 <1
Other registered nurse (no consultant) 9 2.7
Only see non-medical staff 1 <1
Subtotal 337
Not applicable 6
Unanswered 7
Total 350
21
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Pre-operative psychological evaluation to be youth, male, depression and anxiety and personality
disorders.27 Body dysmorphic disorder is not uncommon
The decision to undertake cosmetic surgery lies with in patients seeking cosmetic surgery. It is estimated that
the patient and surgeon. The role of psychological up to 5-15% cosmetic surgery patients may be suffering
assessment is to inform that decision-making process. from the disorder.28 Cosmetic surgery may not be
Sarwar and Crerand (2004) drew two tentative appropriate in this group of patients.
conclusions from their investigation of patients
undergoing cosmetic surgery. Firstly that this population Psychological assessment of patients will be of use
exhibits a variety of psychological symptoms and not only in identifying those patients who might prove
secondly that it is premature to assume that surgery problematic in the operative period, but more importantly,
leads to a positive outcome.26 There are no prospective it will identify patients in whom surgery will be of benefit.
studies that define predictors of poor outcome. However Pre-operative psychological evaluation by a properly
putative factors associated with poor outcome are known trained and or supervised professional should be
standard practice in cosmetic surgery (Table 14).
Table 14. Description of site and routine employment of a psychological evaluation during the initial consultation for
cosmetic surgery.
Psychological evaluation undertaken
Description of site Yes % No % Subtotal Unanswered Total
Independent Hospital - in patient 54 35.8 97 64.2 151 2 153
Non-surgical Treatment Centre 45 45.9 53 54.1 98 2 100
NHS Hospital 4 13.3 26 86.7 30 3 33
Individual Cosmetic Surgeon 3 15.0 17 85.0 20 0 20
Other 3 21.4 11 78.6 14 0 14
Independent Hospital - out patient 7 63.6 4 36.4 11 1 12
Small Clinic (<3 clinicians) 2 28.6 5 71.4 7 1 8
Referral service (abroad) 0 0.0 2 100.0 2 0 2
GP 1 100.0 0 0.0 1 0 1
Referral service (within UK) 0 0.0 1 100.0 1 0 1
Total 119 35.5 216 64.5 335 9 344
22
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These results suggest that the majority of sites fall short the method of training of these individuals. For all sites,
in evaluating patients for psychological disorders prior where an assessment was carried out, it was rare 4/100
to surgery. A wide range of health care professionals (4% of sites reported as standard) for a patient to see a
was reported as carrying out the screening. No evidence Clinical Psychologist (Figure 3).
was provided as to the quality of this assessment or
Number of sites
60
50
40
30
20
10
0
on
se
se
t
t
t
is
lis
is
ur
ur
g
g
e
ia
lo
lo
rg
N
N
ec
ho
ho
Su
or
Sp
yc
yc
on
Ps
Ps
o
lt
e
rg
al
ra
al
Su
ic
ic
r
fe
lin
lin
Re
C
/C
se
ur
N
Healthcare professional
Figure 3. Designation of the healthcare professional carrying out psychological
assessment at sites that carried it out as standard (n = 100, 19 unanswered)
23
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Consent The GMC states that the patient should be given the
opportunity for reflection29 and the IHAS states that
The process of obtaining informed consent from a patient patients should have a two week cooling off period
is well documented. It is a basic tenet of good medical to consider and think over their decision to have an
practice.29 operation.25
Table 15 shows that the surgeon obtained consent for the As an example, sites that offered a major surgical
procedure in all cases in the majority of sites (295/342); proceedure such as rhinoplasty were looked at in more
this is in line with the GMC’s outline of good medical detail. Of these sites that offered rhinoplasty 77/237 did
practice.29 Of more concern is the apparent lack of not undertake a two-stage consent process (Table 17).
adherence to a two-stage consent process (Table 16). Thirty-three of these were Independent Hospitals with in
patient beds.
Table 15. Who obtained consent
Who obtained consent Total %
Always/Only Consultant Surgeon 295 86.3
Consultant or Trainee Surgeon 15 4.4
Consultant, Trainee or Non-consultant Specialist 4 1.2
Surgeon or Specialist Nurse Practitioner 2 <1
Consultant Surgeon or Non-consultant Specialist 3 <1
Consultant Surgeon or Trainee - trained in obtaining consent 6 1.8
Consultant Surgeon/ Specialist Nurse Practitioner 2 <1
Consultant Surgeon or Nurse 10 2.9
Non-consultant Specialist 4 1.2
GP 1 <1
Subtotal 342
Unanswered 2
Total 344
24
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Table 16. Two-stage (deferred) consent process utilised
Two-stage consent process used
Description of site Yes % No % Subtotal Unanswered Total
Independent Hospital - in patient 101 74.8 34 25.2 135 18 153
Non-surgical Treatment Centre 39 54.2 33 45.8 72 28 100
NHS Hospital 20 66.7 10 33.3 30 3 33
Individual Cosmetic Surgeon 10 66.7 5 33.3 15 5 20
Other 10 76.9 3 23.1 13 1 14
Independent Hospital - out patient 7 87.5 1 12.5 8 4 12
Small clinic 1 20.0 4 80.0 5 3 8
Referral Service (abroad) 1 50.0 1 50.0 2 0 2
Referral Service (UK) 1 100.0 0 0.0 1 0 1
GP 1 100.0 0 0.0 1 0 1
Total 191 67.7 91 32.3 282 62 344
Table 17. Type of site offering rhinoplasty and whether a two-stage consent process is utilised
Two-stage consent process used
Description of site Yes % No % Subtotal Unanswered Total
Independent Hospital - inpatient 100 75.2 33 24.8 133 16 149
Non-surgical Treatment Centre 33 51.6 31 48.4 64 25 89
NHS Hospital 8 53.3 7 46.7 15 2 17
Independent Cosmetic Surgeon 8 88.9 1 11.1 9 2 11
Other 6 75.0 2 25.0 8 1 9
Small clinic (<3 clinicians) 1 50.0 1 50.0 2 2 4
Independent Hospital 2 66.7 1 33.3 3 0 3
Referral service (abroad) 1 50.0 1 50.0 2 0 2
Referral service (within UK) 1 100.0 0 0.0 1 0 1
Total 160 67.5 77 32.5 237 48 285
25
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AN – A
2
The GMC clearly states that consent must be sought Pre-anaesthetic assessment
before commencing examination, treatment or the
provision of care.29 The seeking and giving of consent The Royal College of Anaesthetists has highlighted the
should be a process, rather than a one-off event. For importance of pre-operative assessment. In addition
major interventions, it is good practice where possible to to assessing the patient’s fitness for surgery, the pre-
seek the individual’s consent to the proposed procedure operative assessment provides a further opportunity to
well in advance, when there is time to respond to the clarify the information that they have been provided with
individual’s questions and provide adequate information. as part of an ongoing participative consent process, and
Clinicians should then check, on the day of surgery, that minimise the chances of patients making ill-informed
the individual still consents. If an individual is not asked to or inappropriate treatment choices.30 Table 18 shows
signify their consent until just before the procedure is due whether sites routinely carried out a pre-anaesthetic
to start, at a time when they may be feeling particularly assessment on cosmetic surgery patients.
vulnerable, there may be real doubt as to the validity of
consent.
Table 18. Type of site and whether a pre-operative anaesthetic assessment was performed
Pre-anaesthetic assessment performed
Description of site Yes % No % Subtotal Unanswered Total
Independent Hospital - in patients 146 96.7 5 3.3 151 2 153
Non-surgical treatment centre 96 98.0 2 2.0 98 2 100
NHS Hospital 33 100.0 0 0.0 33 0 33
Individual cosmetic surgeon 19 100.0 0 0.0 19 1 20
Other 14 100.0 0 0.0 14 0 14
Independent Hospital - out patients 7 63.6 4 36.4 11 1 12
Small clinic (<3 clinicians) 7 87.5 1 12.5 8 0 8
Referral service (abroad) 2 100.0 0 0.0 2 0 2
GP 0 0.0 1 100.0 1 0 1
Referral service (UK) 1 100.0 0 0.0 1 0 1
Total 325 96.2 13 3.8 338 6 344
The majority of sites (325/338) performed a pre-anaesthetic
assessment. However, there were five independent
hospitals, one small clinic and a GP all performing surgery
but not undertaking pre-anaesthetic assessment.
26
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3 – The structure and case mix of teams providing cosmetic surgery
Types and numbers of procedures When the procedures offered were considered against the
number actually performed (Tables 19 and 20) there was
The number of sites offering each different type of disparity from site to site, with some offering procedures
cosmetic surgical procedure is shown in Figure 4. These that were rarely performed. It is recommended that
data come both from sites that carry out the procedures surgical teams carry out a threshold number of cases
on site and sites that carry out the procedure elsewhere. per annum to ensure their skills are maintained. This
The four commonest procedures were related to breast, is in line with other areas of clinical practice where
eye and nose procedures and liposuction. In 2005 The recommendations are made on case load in order that
Healthcare Commission reported similar findings – breast specialists maintain their skills and morbidity/mortality is
(42.9%), nose (9.6%), liposuctions (8.8%) and eyelid minimised. It is established that higher volume hospitals
(6.3%).2 are associated with a lower mortality.32,33
Number of sites
350
300
250
200
150
100
50
0
ha tion
re sty
n
as sty
st pos xy
re n
on
t
ty
Br a
ap t
y
rre t
Th n
io ft
no ty
rm y
tto ft (M s
m )
im t
Bo t
Th lift
en ift
n
ns y
os nt
la tion
or t
n
S
lif
lif
co klif
an
an
en
st
t
ie
st
ti
Rh ctio
io
io
io
io
i
as
as
de las
hl
gm dl
a
AC
pe
ce
ow
dy
as
si
at
la
la
la
la
sc uct
ct
Va tat
at
pl
pl
pl
em
ec
ig
au rea
ta
uc
vi
yn apl
pl
ea rop
op
p
H nop
m
Fa
to
du
en
N
rg
co
t/i
st
nn
bi
in
ra
fo
nd ch
ek
m
ar
hi
gi
Pe r lip
re
lif
La
M
ae
rt
Bu eli
Pi
Li
en
ug
st
a
Su the y r
he
ep
ry
ck
in
ai
Br
c
se
en ear
a
y/
et
ar
C
Bl
s
fa
sk
G
ni
Br
st
lip
m
La
re
on
ea
la
r
sy
co
Fo
al
op
si
Br
as
ic
Se
O
in
rg
st
sp
m
Su
ea
do
Br
Ab
al
ni
ra
C
ss
ce
Ac
al
im
in
M
Procedure type
Figure 4. Number of sites at which each procedure is offered
27
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Table 19 displays the ten most frequently offered surgery on site) was 228 but for each procedure, the
procedures, showing the number of sites performing each denominator is the number of sites within the sample
frequency range of procedures during one financial year. offering the procedure (minus the sites which did not
The maximum number of sites (that carry out cosmetic provide this data).
Table 19. Ten most frequently offered procedures-number of sites performing each frequency range of procedures during
one year. Ranges of number of procedures performed
10 most
commonly
offered
procedures 0 % 1-10 % 11-20 % 21-50 % 51-100 %
Breast Augmentation 4 2.3 31 17.5 33 18.6 40 22.6 37 20.9
Breast Reduction 13 7.4 84 47.7 42 23.9 27 15.3 6 3.4
Rhinoplasty 9 5.8 66 42.6 27 17.4 37 23.9 8 5.2
Mastopexy 19 13.0 87 57.6 21 13.9 16 10.6 3 2.0
Abdominoplasty 9 5.7 67 42.4 30 19.0 37 23.4 8 5.1
Liposuction 12 8.1 64 43.2 30 20.3 29 19.6 6 4.1
Facelift 10 7.8 66 51.2 23 17.8 24 18.6 4 3.1
Pinnaplasty 28 19.0 99 67.3 6 4.08 11 7.5 1 <1
Gynaecomastia 28 21.0 94 70.7 7 5.26 2 1.5 1 <1
Upper Blepharoplasty 7 4.2 79 47.0 39 23.2 33 19.6 5 3.0
Lower Blepharoplasty 11 7.3 96 63.6 27 17.9 14 9.3 0 0.0
10 most
commonly
offered
procedures 101-200 % 201-1000 % >1000 % Subtotal Procedure Procedure Total
continued offered not offered
but no data
Breast Augmentation 15 8.5 12 6.8 5 2.8 177 27 24 228
Breast Reduction 4 2.3 0 0.0 0 0.0 176 25 27 228
Rhinoplasty 3 1.9 4 2.6 1 <1 155 32 41 228
Mastopexy 2 1.3 3 2.0 0 0.0 151 34 43 228
Abdominoplasty 5 3.2 2 1.3 0 0.0 158 26 44 228
Liposuction 1 <1 6 4.1 0 0.0 148 32 48 228
Facelift 1 <1 1 0.8 0 0.0 129 28 71 228
Pinnaplasty 2 1.4 0 0.0 0 0.0 147 27 54 228
Gynaecomastia 0 0.0 1 0.8 0 0.0 133 39 56 228
Upper Blepharoplasty 2 1.2 3 1.8 0 0.0 168 28 32 228
Lower Blepharoplasty 2 1.3 1 0.7 0 0.0 151 39 38 228
28
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PR AS HE
C –T
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It is of note that for each procedure approximately year as opposed to 10 times per year. Experience and
10% of sites could not provide data on the numbers competence run hand in hand. As shown in Table 20,
of procedures performed. Breast augmentations were with the exception of breast augmentation, the majority
performed most frequently with 5/177 sites performing of centres performed fewer than 20 of the offered
more than 1000 procedures during one financial year. procedures per year. Patients should enquire how often
Other procedures were performed less frequently. the procedure they wish to have is carried out at the sites
Table 20 shows the percentage of sites that perform they are considering attending. National regulatory bodies
each procedure less than (or equal to) 50 and less should set minimum requirements for surgeons and
than (or equal to) 20 times during the financial year. indeed surgical teams to be considered competent. This
has occurred in Singapore with respect to the minimum
One would expect patients to choose a surgical team number of cosmetic surgical operations performed by
that performs a particular procedure say 100 times per individual surgeons.31
Table 20. Percentage of sites performing procedures ≤50 and ≤20 times per annum
10 most commonly Total % Total %
offered procedures ≤50 per annum ≤50 per annum ≤20 per annum ≤20 per annum Subtotal
Breast Augmentation 108 61.0 68 38.4 177
Breast Reduction 166 94.3 139 79.0 176
Rhinoplasty 102 89.7 139 65.8 155
Mastopexy 143 94.7 127 84.1 151
Abdominoplasty 143 90.5 106 67.1 158
Liposuction 135 91.2 106 71.6 148
Facelift 123 95.3 99 76.7 129
Pinnaplasty 144 98.0 133 90.5 147
Gynaecomastia 131 98.5 129 97.0 133
Upper Blepharoplasty 158 94.0 125 74.4 168
Lower Blepharoplasty 148 98.0 134 88.7 151
29
ET S ND
SM M A
O A RE
IC
Y G C TE TU
ER IN OF C
U
R VID IX TR
SU O E M S
PR AS HE
C –T
3
G
Table 21. Designation of the person performing the surgery
Who performs cosmetic surgery Total %
Consultant surgeon 194 85.5
Consultant/Trainee surgeon 15 6.6
Consultant/Trainee surgeon/Non-consultant Specialist 5 2.2
Consultant Surgeon/ Non-consultant Specialist 3 1.3
Cons Surgeon/ Specialist Nurse Practitioner 2 <1
Consultant Surgeon/ Specialist Nurse Practitioner/Other Nurse 1 <1
Consultant Surgeon/Other 1 <1
Non-consultant Specialist 4 1.8
Non-consultant Specialist/Other 1 <1
GP 1 <1
Subtotal 227
Unanswered 1
Total 228
Delivery of surgery Surgeons responsible for the cosmetic surgery are from
a variety of specialties (Figure 5 and Table 22) and should
Table 21 shows the number of sites where cosmetic ideally be listed on an appropriate specialist register.
surgery was performed by each grade of clinician. In However, cosmetic surgery is yet to be recognised as
most cases (194/227) cosmetic surgery was said to be a specialty for registration purposes, and the training
always and only carried out by a consultant surgeon. and experience in cosmetic surgery of surgeons on the
However, no evidence was provided as to the presence of existing specialist lists cannot be assured by the existing
an individual consultant on the GMC’s specialist register certification process.
and the term ‘consultant’ may be used for differing
standards of practitioner outside the NHS.
Table 22. Specialties carrying out cosmetic surgery
Specialties carrying out cosmetic surgery Total %
Answer includes non-surgical specialty 38 17
Answer includes surgical specialties 185 83
Subtotal 223
Unanswered 5
Total 228
30
ET S ND
SM M A
O A RE
IC
Y G C TE TU
F C
G DI X O U
VI I TR
SU RO E M S
E
AS H
ER N
C –T
3
R
P
Number of sites
250
200
150
100
50
0
ry
at
ry
ry
y
y
y
e
e
er
ed
og
og
og
in
ic
e
ge
ge
ro
th
er
ct
ic
rg
ol
ol
ol
th
O
ur
ur
w
ed
ra
su
at
m
c
ns
s
ls
d
ae
lp
lm
rm
al
an
tic
al
na
ra
th
yn
ra
ci
De
ra
as
e
e
U
ph
e
-fa
G
en
s
e
en
Pl
no
en
O
G
illo
G
G
r,
ax
Ea
M
Specialty
Figure 5. Specialties carrying out cosmetic surgery.
Those that selected ‘Other’ specified cosmetic surgery, cosmetic medicine, genitourinary
and hand surgery as specialities carrying out cosmetic surgery at their site.
Table 23. Cosmetic surgery training provided
Cosmetic surgery training given
Description of site Yes % No % Subtotal Unanswered Total
Independent Hospitals 9 5.5 156 94.5 165 6 171
NHS Hospitals 23 65.7 12 34.3 35 2 37
All other sites 3 15.0 17 85.0 20 0 20
Total 35 15.9 185 84.1 220 8 228
Provision of training Traditionally, surgical training has been provided
exclusively in the NHS. Cosmetic surgery might present
Training in cosmetic surgery was available only in 35/220 an opportunity to increase training within the independent
(15.9%) sites. The remaining 185 sites did not provide health care sector. Table 23 shows the number of
any training, and this represents a substantial loss of sites offering training in cosmetic surgery techniques
training opportunities in cosmetic surgery. Future patients (answers are grouped by whether the site is an NHS or
would be better served if formal training programmes independent hospital).
were established across the health care environment.
31
ET S ND
SM M A
O A RE
IC
Y G C TE TU
ER IN OF C
U
R VID IX TR
SU O E M S
PR AS HE
C –T
3
G
Consultant rota for anaesthetic sessions Table 25 shows who covered the postoperative care out
of hours. It is important that both staff and patients have
Only 92/138 (67%) independent hospitals with overnight access to a surgical opinion throughout any cosmetic
beds had a dedicated consultant rota for anaesthetic surgery episode.
sessions. Of all sites carrying out cosmetic surgery
that returned a questionnaire 136/192 (70.8%) had a The GMC requires that doctors provide adequate
dedicated cosmetic surgery anaesthetic rota (Table 24). postoperative support to patients under their care.6
From the respondents 25/228 sites did not answer
this question.
Table 24. Description of site, and existence of a dedicated consultant rota covering anaesthetic sessions
Consultant rota for cosmetic surgery
Description of site Yes % No % Subtotal NA Unanswered Total
Independent Hospital - in patient 92 66.7 46 33.3 138 17 4 159
NHS Hospital 36 100.0 0 0.0 36 0 1 37
Independent Hospital - out patient 0 0.0 6 100.0 6 5 1 12
Other 5 62.5 3 37.5 8 1 1 10
Small Clinic (<3 clinicians) 1 50.0 1 50.0 2 3 2 7
Clinic (>3 Clinicians) 2 100.0 0 0.0 2 0 0 2
GP 0 0.0 0 0.0 0 1 0 1
Total 136 70.8 56 29.2 192 27 9 228
Table 25. Out of hours cover for postoperative surgical care
Postoperative care Total %
Nursing staff plus: surgeon/resident medical officer/ anaesthetist 82 40.4
Resident medical officer plus: surgeon/nurse/anaesthetist 51 25.1
On-call team 27 13.3
Surgeon plus: Nurse/resident medical officer/anaesthetist 16 7.9
Other doctor plus: surgeon/nurse/anaesthetist 14 6.9
Recovery staff/anaesthetist 4 2.0
Other hospital staff 4 2.0
Clinicians carrying out the procedure 2 1.0
NA 3 1.5
Subtotal 203
Unanswered 25
Total 228
32
ET S ND
SM M A
O A RE
IC
Y G C TE TU
ER IN OF C
U
R VID IX TR
SU O E M S
PR AS HE
C –T
3
G
Number of sites Consultant anaesthetist Trainee anaesthetist
250 Clinician carrying out the operation Physicians assistant
Non-consultant specialist
200
150
100
50
0
General anaesthetic Local anaesthetic Sedation
Type of anaesthesia
Figure 6. Designation of the person who delivered different types of anaesthesia
Delivery of anaesthesia specialist societies recognise that sedation, as an adjunct
to good pain relief and sympathetic patient management,
The majority of general anaesthetics were administered can improve both patient tolerance and acceptance.35
by consultant anaesthetists (207/228). Non-consultant Furthermore it can increase the technical success of
specialists gave anaesthetics rarely (13/228) and two sites the procedure, but at all times patient safety must be
reported that Physicians Assistants (anaesthesia) delivered preserved. The Academy has found that many users of
general anaesthesia (Figure 6). This should be under the sedation have received no formal training and that they
supervision of a consultant anaesthetist as required by the do not follow existing guidelines - often because they
Royal College of Anaesthetists.34 are not even aware of them.35 As a result patients are
being exposed to unnecessary risk. Patients must ensure
Clinicians carrying out the operation often gave local and indeed demand that those delivering sedation have
anaesthetic (LA) or sedation 36/178 (20%) (Table 26). received formal training in sedation techniques.
The Academy of Medical Royal Colleges and associated
Table 26. Types of anaesthesia given by the ‘clinician carrying out the operation’
Description of site LA LA, Sedation Sedation Subtotal Unanswered Total
Independent Hospital - in patient 98 27 1 126 33 159
NHS Hospital 25 4 0 29 8 37
Independent Hospital - out patient 7 0 0 7 5 12
Other 6 3 0 9 1 10
Small Clinic (<3 clinicians) 5 1 0 6 1 7
Clinic (>3 clinicians) 0 0 0 0 2 2
GP 1 0 0 1 0 1
Total 142 35 1 178 50 228
33
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FA OL OS
F –P
4
4 – Postoperative follow up, policies, facilities and protocols
The care pathway for patients undergoing cosmetic Postoperative appointment
surgery is no different to that of other specialties.
From referral for surgery to their discharge following a Table 27 shows that all sites that answered the question
surgical episode, outcome and patient satisfaction may organise a postoperative appointment in line with good
be affected at each step of the care pathway. In other practice.36
surgical specialties it is routine for patients to be reviewed
and supported in the postoperative period. Protocols
and pathways should be in place for every eventuality
following surgery. Sites should be equipped to deal with
any eventuality. Complacency in equipping clinical areas
will affect patient outcomes if there is any potential for a
reduction in recognised levels of safety.36
Table 27. Description of site and organisation of postoperative appointment
Postoperative appointment organised
Description of site Yes No Unanswered Total
Independent Hospital - in patient 153 0 0 153
Non-surgical Treatment centre 95 0 5 100
NHS Hospital 33 0 0 33
Individual Cosmetic Surgeon 20 0 0 20
Other 14 0 0 14
Independent Hospital - out patient 12 0 0 12
Small Clinic (<3 clinicians) 8 0 0 8
Referral Service (abroad) 2 0 0 2
GP 1 0 0 1
Referral Service (UK) 1 0 0 1
Total 339 0 5 344
34
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TO IE P R
O ILIT W U PE
PR C LO TO
FA OL OS
F –P
4
Table 28. Description of site and provision of patient information card
Information card provided
Description of site Yes % No % Subtotal Unanswered Total
Independent Hospital - in patient 144 96.0 6 4.0 150 3 153
Non-surgical Treatment Centre 91 98.9 1 1.1 92 8 100
NHS Hospital 26 81.3 6 18.8 32 1 33
Individual Cosmetic Surgeon 18 90.0 2 10.0 20 0 20
Other 13 92.9 1 7.1 14 0 14
Independent Hospital - out patient 8 66.7 4 33.3 12 0 12
Small Clinic (<3 clinicians) 8 100.0 0 0.0 8 0 8
Referral Service (abroad) 2 100.0 0 0.0 2 0 2
GP 1 100.0 0 0.0 1 0 1
Referral Service (UK) 1 100.0 0 0.0 1 0 1
Total 312 94.0 20 6.0 332 12 344
However, 20 out of 332 sites stated that they did not Emergency telephone hotline
provide patients with an information card of contact
details and information on what to do in case of It was of note that 45 of 334 (13.5%) sites did not specify
complications, for use in the immediate postoperative that they had a telephone help line for patients to call
period (Table 28). (Table 29). A further 10 sites did not answer the question.
Table 29. Description of site and provision of telephone helpline
Telephone helpline
Description Of site Yes % No % Subtotal Unanswered Total
Independent Hospital - in patient 126 83.4 25 16.6 151 2 153
Non-surgical Treatment Centre 93 100.0 0 0.0 93 7 100
NHS Hospital 18 56.3 14 43.8 32 1 33
Individual Cosmetic Surgeon 20 100.0 0 0.0 20 0 20
Other 10 71.4 4 28.6 14 0 14
Independent Hospital - out patient 11 91.7 1 8.3 12 0 12
Small Clinic (<3 clinicians) 7 87.5 1 12.5 8 0 8
Referral Service (abroad) 2 100.0 0 0.0 2 0 2
GP 1 100.0 0 0.0 1 0 1
Referral Service ( UK) 1 100.0 0 0.0 1 0 1
Total 289 86.5 45 13.5 334 10 344
35
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PR C LO TO
FA OL OS
F –P
4
Of those sites that claimed to have had a telephone help If complications resulting from the procedure necessitate
line for patients (289), 15/284 (5%) stated that it was not re-admission (assuming the patient has followed all
available 24 hours /day (five sites did not answer - data advice on after care), 35/332 sites suggested that the
not shown). NHS would be responsible for the cost of readmission.
Thirty of these sites were NHS hospitals.
Re-admission Three sites said that the patient or the NHS would be
responsible and 22/332 (6.6%) stated that the patient
All independent providers of health care should have would be responsible for costs incurred (Table 31).
policies for the re-admission of patients following surgery.
There were 39/216 (18%) sites that did not have a policy
for the emergency re-admission of patients (Table 30).
The default position would be that the NHS would care
for these patients should they require re-admission and
hence shoulder the cost.
Table 30. Description of site that carry out cosmetic surgery on site and that have a policy for the re-admission of cosmetic
surgery patients.
Site had a policy for patient re-admission
Description of site Yes % No % Subtotal Unanswered Total
Independent Hospital - in patient 138 90.2 15 9.8 153 6 159
NHS Hospital 24 72.7 9 27.3 33 4 37
Independent Hospital - out patient 5 41.7 7 58.3 12 0 12
Other 7 70 3 30 10 0 10
Small Clinic (<3 clinicians) 1 20 4 80 5 2 7
Clinic (>3 clinicians) 2 100 0 0 2 0 2
GP 0 0 1 100 1 0 1
Total 177 81.9 39 18.1 216 12 228
36
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O A O IV
IE
C S , P AT
D IC
TO IE P R
O ILIT W U PE
PR C LO TO
FA OL OS
F –P
4
nt
ie
Table 31. Covering the cost of a re-admission
t
pa
e
th
ed
rr
fe
re
at
th
ite
ry
/s
e
rg
ry
su
e
rg
nt
ic
su
tie
et
pa
sm
ic
S
et
H
e
co
N
sm
th
he
e
ed
co
th
rt
rr
g
g
o
fe
in
in
ed
nt
nt
re
id
id
n
er
tie
tie
ov
ov
S
al
at
w
Description
w
H
pa
pa
ot
pr
pr
no
th
ns
N
er
al
bt
nk
te
te
te
na
of site
e
e
e
th
t
Su
Th
Th
Th
To
Si
Si
Si
O
U
U
Independent
Hospital –
in patient 12 125 3 2 0 1 2 3 148 11 159
NHS Hospital 0 1 0 0 1 30 0 0 32 5 37
Non-surgical
Treatment
Centre 2 58 0 26 0 1 0 4 91 9 100
Independent
Hospital –
out patient 3 6 0 0 0 0 0 2 11 1 12
Small Clinic
(<3 clinicians) 0 5 0 1 0 1 1 0 8 0 8
Referral Service
(abroad) 1 1 0 1 1 0 0 0 4 0 4
Individual Cosmetic
Surgeon 3 14 0 0 0 0 3 1 21 0 21
Referral Service
(UK) 0 1 0 2 0 0 0 0 3 0 3
GP 0 0 0 0 0 0 0 1 1 0 1
Other 1 6 0 2 1 2 0 1 13 1 14
Clinic 0 0 0 0 0 0 0 0 0 2 2
Total 22 217 3 34 3 35 6 12 332 29 361
37
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TO IE P R
O ILIT W U PE
PR C LO TO
FA OL OS
F –P
4
The referral of patients abroad the 17 sites that responded, 14/17 made some provision
for the translation of patient information into English,
Doctors are required to “act in their patient’s best 15/17 provided patient support before and after the
interests when making referrals and providing or procedure, 16/17 claimed that they ensure standards
arranging treatment or care”.18 Those referring patients are equivalent to the UK and 16/17 claimed that there
abroad need to ensure that follow-up and emergency are extensive provisions in place to deal with any
backup in the postoperative period are available. complications that might arise after the patient returns to
the UK. These data suggest good practice; however, it
Only 17/341 sites claimed to refer patients abroad is a very small sample of sites that responded. The size
(Table 32); of these, four sites described themselves of the sample and the lack of response make it difficult
exclusively as a “Cosmetic Surgery Referral Service for to draw any meaningful conclusions as to the quality of
surgery outside the UK”. Only these four sites returned the care of cosmetic surgery patients abroad. The lack
questionnaires out of a possible 31 of this site type that of participation and difficulties in obtaining information
were sent one. The 31 sites that were included were out from sites that have no administrative base in the UK may
of 130 sites that were identified, but which did not have reflect the wider problems in regulating this sector of the
an address in the UK and so could not be included. Of cosmetic surgery industry.
Table 32. Description of site and whether patients were referred abroad
Patients referred abroad
Description of site Yes % No % Subtotal Unanswered Total
Independent Hospital - in patient 1 <1 152 99.3 153 1 154
NHS Hospital 0 0.0 33 100.0 33 0 33
Non-surgical Treatment Centre 12 12.9 81 87.1 93 7 100
Independent Hospital - out patient 0 0.0 12 100.0 12 0 12
Small Clinic (<3 clinicians) 0 0.0 8 100.0 8 0 8
Referral Service (Abroad) 4 100.0 0 0.0 4 0 4
Individual Cosmetic Surgeon 0 0.0 20 100.0 20 1 21
Referral Service (UK) 0 0.0 3 100.0 3 0 3
GP 0 0.0 1 100.0 1 0 1
Other 0 0.0 14 100.0 14 0 14
Total 17 5.0 324 95.0 341 9 350
38
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Facilities available Table 33. Number of sites in which equipment from a
required list was available/missing
The same level of patient monitoring is required Equipment available/missing Total
whether the patient is treated in an isolated operating Full set of equipment 101
environment, a large NHS or independent sector
1 item missing 62
hospitals.
2 items missing 28
The questionnaires were analysed to identify if the 3 items missing 20
equipment listed was immediately available in theatre:
4 items missing 6
ECG, temperature measurement, capnography, Doppler
5 items missing 5
ultrasound, nerve stimulator, oxygen supply and pulse
oximetry. Only 101/226 (44.6%) of sites had a fully Temperature measurement only 2
equipped operating department (Tables 33 and 34). Oxygen supply only 1
ECG only 1
Subtotal 226
Unanswered 2
Table 34. The number of sites that stated each item of Total 228
equipment on the list was available
t
en
m
n
re
tio
su
nd
uc
ea
ou
/s
or
m
er
ly
at
as
hy
pp
et
re
ul
tr
ed
ap
im
im
tu
su
ul
er
gr
ra
ox
al
st
er
n
w
ot
pe
no
ge
pl
ve
ns
se
al
bt
G
m
op
ap
xy
er
na
l
t
Site type
EC
Pu
Su
To
Te
O
C
D
N
U
Independent Hospital -
in patient 159 159 113 112 120 158 159 159 0 159
Independent Hospital -
out patient 5 8 2 1 1 10 9 12 0 12
NHS Hospital 36 36 35 23 30 35 34 36 1 37
Clinic
(>3 Clinicians) 2 2 0 0 0 2 2 2 0 2
Small clinic
(<3 clinicians) 2 3 0 0 0 5 4 6 1 7
GP 1 1 0 0 0 1 1 1 0 1
Other 10 10 8 8 6 9 9 10 0 10
Total 215 219 158 144 157 220 218 226 2 228
39
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FA OL OS
F –P
4
There was not a great difference between NHS and These recommendations state the monitoring devices
inpatient independent hospitals, approximately 50% which are essential and those which must be immediately
of each being fully equipped. available during anaesthesia. If it is necessary to continue
anaesthesia without a device categorised as ‘essential’,
Good Medical Practice (GMC) states that a the anaesthetist must clearly note the reasons for this in
practitioner must ensure that the premises are the anaesthetic record.
suitable and the equipment available is appropriate
and adequate for the procedures or treatment
provided and all are able to treat patients safely.18 Procedures performed outside of an
The Association of Anaesthetists of Great Britain operating theatre
and Ireland (AAGBI) has issued standards required
for patient monitoring.37 The same standards of Only 13 sites claimed to undertake minor surgery away
monitoring apply when the anaesthetist is responsible from a formal operating theatre (Table 35). Yet in five
for a local /regional anaesthetic or sedative technique sites this was stated to include procedures such as
for an operative procedure. blepharoplasty and labiaplasty.
Table 35. Procedures carried out away from a formal operating theatre
Details of procedures carried out in non-theatre environment Total
Hair transplant in treatment room 3
Under local anaesthetic 1
Minor surgery 1
Minor surgery: Blepharoplasty (in treatment room) 1
Minor surgery: Pinnaplasty,Blepharoplasty, Scar revision, Labiaplasty, Earlobe surgery 1
Thread/Suture face lift 1
Thread/Suture facelift, Blepharoplasty (In treatment room in outpatient department) 1
Upper Blepharoplasty, Pinnaplasty, Otoplasty- carried out in treatment rooms 1
Minor Ops Room: Minor operations: upper/lower Blepharoplasty - under local anaesthetic 1
Out-patient procedures 2
Total 13
If surgery of the nature listed above is not carried out in
a theatre environment, the question of sterility must be
raised and hence patients may be at risk of postoperative
infection. The true scale of this practice cannot be
estimated as a number of sites did not respond to the
questionnaire.
40
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4
Recovery under local anaesthesia but also including more major
procedures such as abdominoplasty and breast
After general or regional anaesthesia, all patients should augmentation that would normally require a general
recover in a specially designated area, which should anaesthetic.
conform to the guidelines of the Department of Health
(DH) and the AAGBI for design and equipment.38 Twenty four independent hospitals reported having Level
3 postoperative care (Table 37). In those sites without
Three sites stated that they did not have pulse oximetry in Level 3 care, all apart from two sites had an operational
their recovery areas (Table 36). These were two day case protocol for patient transfer in the event of an untoward
independent hospitals and one small clinic that carried peri-operative event (Table 38).
out a number of procedures that may be performed
Table 36. Description of site and availability of Pulse oximetry equipment in the recovery area
Pulse oximetry in the recovery area
Description of site Yes % No % Subtotal Unanswered Total
Independent Hospital - in patient 158 100.0 0 0.0 158 1 159
Independent Hospital - out patient 10 83.3 2 16.7 12 0 12
NHS Hospital 36 100.0 0 0.0 36 1 37
Small Clinic (<3 clinicians) 4 80.0 1 20.0 5 2 7
Clinic (>3 clinicians) 2 100.0 0 0.0 2 0 2
GP 1 100.0 0 0.0 1 0 1
Other 10 100.0 0 0.0 10 0 10
Total 221 98.7 3 1.3 224 4 228
Table 37. Description of site and presence of a Level 3 care unit on site
Level 3 care on site
Description of site Yes % No % Subtotal Unanswered Total
Independent Hospital - in patient 24 15.2 134 84.8 158 1 159
Independent Hospital - out patient 0 0.0 12 100 12 0 12
NHS Hospital 34 94.4 2 5.6 36 1 37
Small Clinic (<3 clinicians) 0 0.0 5 100 5 2 7
Clinic (>3 clinicians) 0 0.0 2 100 2 0 2
GP 0 0.0 1 100 1 0 1
Other 5 50.0 5 50 10 0 10
Total 63 28.1 161 71.9 224 4 228
41
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PR C LO TO
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F –P
4
Table 38. Description of site and the existence and type of standard procedure for transfer from theatre in event of peri-
operative complication
e
ita Ne cy
ur
l
by
ita
y
sp t/ en
nc
ed
l ar
sp
ho en erg
t ge
oc
ho
en er
ut rtm Em
pr
e
tm m
ed
rd
ut
ar e E
ep ite
da
ac
er
D ns
la
ep it
w
an
y
ac a
ot
D ns
ns
rb
O
er
st
e
bt
l
ta
na
ea
O
th
Description of site
Su
o
To
O
N
N
U
Independent Hospital -
in patient 11 19 120 0 6 156 3 159
NHS Hospital 16 1 4 3 10 34 3 37
Independent Hospital -
out patient 1 0 11 0 0 12 0 12
Other 2 1 4 0 0 7 3 10
Small Clinic
(<3 clinicians) 0 0 2 0 3 5 2 7
Clinic
(>3 clinicians) 0 0 2 0 0 2 0 2
GP 0 0 1 0 0 1 0 1
Total 30 21 144 3 19 217 11 228
Table 39. Level 2 care unit on site
Level 2 care unit on site
Description of site Yes % No % Subtotal Unanswered Total
Independent Hospital - in patient 113 72.9 42 27.1 155 4 159
Independent Hospital - out patient 1 8.3 11 91.7 12 0 12
NHS Hospital 34 97.1 1 2.9 35 2 37
Small Clinic (<3 clinicians) 0 0.0 5 100.0 5 2 7
Clinic (>3 clinicians) 0 0.0 2 100.0 2 0 2
GP 0 0.0 1 100.0 1 0 1
Other 5 50.0 5 50.0 10 0 10
Total 153 69.5 67 30.5 220 8 228
All sites carrying out acute elective surgery should have Of the sites in this study, 67/220 (30.5%) did not have a
the ability to deliver Level 2 postoperative care at least Level 2 care unit on site (see Table 39).
until a patient might be transferred to another site.39
42
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4
Provision for resuscitation Resuscitation training
One site answered that resuscitation equipment was The dataset showed that 220 of 222 sites gave regular
unavailable in areas where the surgery/anaesthesia took resuscitation training to their recovery staff in line with
place. Four sites did not answer the question (Table 40). CQC requirements (Table 41). However, only 166/224
(74.1%) sites could state that there would always be a
member of staff on duty that holds full provider certificate
(e.g. ALS).
Table 40. Description of site and provision of resuscitation
Resuscitation equipment on site
Description of site Yes No Subtotal Unanswered Total
Independent Hospital - in patient 158 0 158 1 159
NHS Hospital 36 0 36 1 37
Other 10 0 10 0 10
Independent Hospital - out patient 12 0 12 0 12
Small Clinic (<3 clinicians) 4 1 5 2 7
Clinic (>3 clinicians) 2 0 2 0 2
GP 1 0 1 0 1
Total 223 1 224 4 228
Table 41. Description of site and provision of resuscitation training
Resuscitation training provided
Description of site Yes NA Subtotal Unanswered Total
Independent Hospital - in patient 158 0 158 1 159
NHS Hospital 36 0 36 1 37
Independent Hospital - out patient 8 1 9 3 12
Other 10 0 10 0 10
Small Clinic (<3 clinicians) 5 1 6 1 7
Clinic (>3 clinicians) 2 0 2 0 2
GP 1 0 1 0 1
Total 220 2 222 6 228
43
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4
Member of staff with full provider certificate
(e.g. ALS)
It is a recommendation of the Royal College of
Anaesthetists30 that at least one member of the recovery
staff on duty has a full Advanced Life Support Certificate.
Table 42. shows that 48 of 214 (22%) respondents did
not adhere to this standard.
Table 42. Description of site type and whether there is always a member staff on duty with a full provider certificate (e.g. ALS)?
Staff on duty with full provider certification
Description of site Yes % No % Subtotal NA Unanswered Total
Independent Hospital - in patient 118 76.6 36 23.4 154 1 4 159
NHS Hospital 27 77.1 8 22.9 35 0 2 37
Independent Hospital - out patient 6 85.7 1 14.3 7 2 3 12
Other 9 90.0 1 10.0 10 0 0 10
Small Clinic (<3 clinicians) 3 60.0 2 40.0 5 0 2 7
Clinic (>3 clinicians) 2 100.0 0 0.0 2 0 0 2
GP 1 100.0 0 0.0 1 0 0 1
Total 166 77.6 48 22.4 214 3 11 228
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5 – Patient records and clinical audit
Both individual clinicians and organisations delivering Medical records - held by the site
health care are required by governing bodies to participate
in audit.18,40 It is a priority of all those delivering care As shown in Table 43 the vast majority of sites (340/342)
to patients to ensure meticulous records are kept in an held a copy of the patients’ medical records in line with
appropriate confidential manner. good medical practice.18
Table 43. Description of site and whether the patients’ medical records are held by the site
Medical records held on site
Description of site Yes % No % Subtotal Unanswered Total
Independent Hospital - in patient 155 99.4 1 0.6 156 3 159
Non-surgical Treatment Centre 97 100.0 0 0.0 97 3 100
NHS Hospital 37 100.0 0 0.0 37 0 37
Individual Cosmetic Surgeon 10 90.9 1 9.1 11 10 21
Other 14 100.0 0 0.0 14 0 14
Independent Hospital - out patient 12 100.0 0 0.0 12 0 12
Small Clinic (<3 clinicians) 8 100.0 0 0.0 8 0 8
Referral Service (UK) 1 100.0 0 0.0 1 3 4
Referral Service (abroad) 3 100.0 0 0.0 3 0 3
Clinic (>3 clinicians) 2 100.0 0 0.0 2 0 2
GP 1 100.0 0 0.0 1 0 1
Total 340 99.4 2 0.6 342 19 361
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Data protection policy Informing patients’ GPs about their surgery
The vast majority of sites: 344/352 (98%) had policies for The majority (323/361 (89.5%) of sites recorded the
the storage of medical records in accordance with the referral route of patients. Of these 291/323 (90%) of sites
Data Protection Act (1998) and good medical practice5 accept patients from sources including those other than a
(Table 44). GP referral (Data not shown). Table 45 displays these 291
sites, showing whether they routinely inform the patients’
GP about their cosmetic surgery (with the patients’
consent) in line with IHAS guidelines.6 12/279 (4.3%) of
these sites did not have a policy of informing the patients’
GP contrary to IHAS guidelines.
Table 44. Description of site and existence of a policy for handling medical records in accordance with the DPA (1998)
Handled data according to the DPA 1998
Description of site Yes % No % Subtotal Unanswered Total
Independent Hospital - in patient 155 98.7 2 1.3 157 2 159
Non-surgical Treatment Centre 97 100.0 0 0.0 97 3 100
NHS Hospital 37 100.0 0 0.0 37 0 37
Individual Cosmetic Surgeon 16 84.2 3 15.8 19 2 21
Other 14 100.0 0 0.0 14 0 14
Independent Hospital - out patient 12 100.0 0 0.0 12 0 12
Small Clinic (<3 clinicians) 7 100.0 0 0.0 7 1 8
Referral Service (UK) 2 66.7 1 33.3 3 1 4
Referral Service (abroad) 1 33.3 2 66.7 3 0 3
Clinic (>3 clinicians) 2 100.0 0 0.0 2 0 2
GP 1 100.0 0 0.0 1 0 1
Total 344 97.7 8 2.3 352 9 361
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Table 45. Description of site and policy to inform the patients’ GP of their surgery
GP informed
Description of site Yes % No % Subtotal Unanswered Total
Independent Hospital - in patient 116 94.3 7 5.7 123 5 128
Non-surgical Treatment Centre 90 96.8 3 3.2 93 2 95
Individual Cosmetic Surgeon 18 100.0 0 0.0 18 1 19
Other 11 91.7 1 8.3 12 1 13
Independent Hospital - out patient 8 88.9 1 11.1 9 3 12
NHS Hospital 9 100.0 0 0.0 9 0 9
Small Clinic (<3 clinicians) 8 100.0 0 0.0 8 0 8
Referral Service (abroad) 3 100.0 0 0.0 3 0 3
Clinic (>3 clinicians) 2 100.0 0 0.0 2 0 2
Referral Service (UK) 2 100.0 0 0.0 2 0 2
Total 267 95.7 12 4.3 279 12 291
Clinical governance The majority of sites 348/361 (96%) specified that they
carried out some form of outcome measurement, with
Outcome measurement is an important aspect of quality over 80% measuring infection rates, re-admission rates
assurance in all surgeons. Sites reported monitoring and/or some form of assessment of patient satisfaction.
outcomes as shown in Table 46, (answers may be However the question was not answered from 13 sites.
multiple from 361 sites).
The type of site from which a questionnaire was
Table 46. Patient outcomes measured received where the question was not answered are
Patient outcomes monitored Total shown in Table 47.
Infection rates 333
Table 47. The types of site that did not respond when asked
Unplanned hospital re-admission rates 324 which patient outcomes were measured
Patient satisfaction questionnaires 315 Description of site Total
Psychosocial assessment 46 Individual Cosmetic Surgeon 3
Complaints 20 Referral Service (UK) 2
Revision rates 19 NHS Hospital 2
Return to theatre 12 Non-surgical Treatment Centre 2
Adverse outcomes/complications/DVT 10 Referral Service (abroad) 2
Length of stay 3 Other 1
Other performance indicators 1 Independent Hospital - in patient 1
Other form of audit 1 Total 13
Unanswered 13
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The CQC requires sites that are registered with them to Table 50 shows the type of site of the 65/361 sites (18%)
report to them on an annual basis. This allows an external from which an answer was not received.
verification of the quality of the clinical practice taking
place.41 Table 48 shows whether sites make audit results Table 50. Type of site that did not answer whether they
available to external regulatory bodies. reported their audit findings to an external body
Description of site Total
Table 48. Number of sites that make the results of their audit
Independent Hospital - in patient 22
available to external regulatory body
NHS Hospital 16
Audit results available Total %
Non-surgical Treatment Centre 10
Yes, CQC 206 69.6
Individual Cosmetic Surgeon 7
Yes (not specified) 42 14.2
Other 4
Yes (other regulatory body) 34 11.5
Referral Service (abroad) 3
No 12 4.1
Referral Service (UK) 2
Unknown 2 <1
Independent Hospital - out patient 1
Subtotal 296
Total 65
Unanswered 65
Total 361
It is of note that 22 independent hospitals with in patients
and 16 NHS hospitals failed to answer this question. The
Of the sites that answered the question 282/296 (95%) guiding principle of any medical intervention is that it is
claimed that the results of their audit are made available effective (successful) and that the patient’s safety is the
to external governing bodies. In 206/296 (69.6%) this was primary goal. Those performing cosmetic surgery should
the CQC. 12/296 (4.1%) of sites claimed that they did not engage in some form of quality review.
make the results of their audit available to any external
governing body. They come from the site types listed in
Table 49.
Table 49. Type of site that did not report audit findings to an
external governing body
Description of site Total
Individual Cosmetic Surgeon 4
Other 2
NHS Hospital 2
Non-surgical Treatment Centre 2
Small Clinic (<3 clinicians) 1
Referral Service (abroad) 1
Total 12
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283/361 (78%) sites stated that they monitor
implementation of action/change in response to their own
audit report by carrying out some form of re-audit, clinical
governance, medical advisory committee meetings,
action plan or clinical effectiveness meetings (data not
shown). Those sites that did not answer the question or
responded negatively come from the site types listed in
Table 51.
Table 51. Description of sites that do not monitor
implementation or action of their audit findings or did not
answer this question
Description of site Total
Independent Hospital – in patient 23
NHS Hospital 17
Non-surgical Treatment Centre 13
Individual Cosmetic Surgeon 11
Other 5
Referral Service (UK) 3
Referral Service (abroad) 3
Independent Hospital - out patient 2
Small Clinic (<3 clinicians) 1
Total 78
In line with other surgical specialties (cardiac surgery and
vascular surgery) the need for morbidity and outcome
data is pressing. The Healthcare Commission had
previously called for the development of assessment
methodology to allow the comparison of outcome
measurements. A national database for cosmetic surgery
should be implemented to allow patients to be better
informed.
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Conclusion
This study highlights the very great difficulties that The establishment of the British Academy of Cosmetic
there are in accurately identifying who is doing what in Practice goes some way toward introducing common
cosmetic surgery and provides a new perspective on the standards, but it is likely that membership will be on
reasons for concern in this sector. Undoubtedly some a voluntary basis, questioning its effectiveness. This
perform well but others could do better. Commercial academy must be inclusive, demonstrating that a
priorities must not influence patient welfare. patient’s outcome is related to the quality of the team
involved in their care. The introduction of a number of
Numerous cosmetic surgery procedures are performed inter-specialty cosmetic surgical training fellowships
each year in the United Kingdom. Previous reports is to be welcomed, but these relatively rare posts are
(Healthcare Commission) have highlighted issues in this insufficient to train the number of surgeons required to
area of medical practice. Focus groups have highlighted deliver the demand for cosmetic surgery. Until there is
areas of concern – brokering of services, regulation of a recognition that the independent sector needs to fully
advertising and assessment of clinical performance contribute to the resourcing of surgical training for those
indicators. procedures performed in the main outside the NHS, the
issue of accreditation and standardisation of training will
The regulation of cosmetic surgery remains poor. not be resolved.
Those representing providers have said that they would
welcome specific regulation. This has not occurred. The report has highlighted areas of concern around the
peri-operative safety of patients. Failure to adequately
This study has reinforced these concerns and highlighted monitor patients is a recipe for disaster, highlighted by
other areas which need attention. As with any other many published case reports. Staff caring for patients
type of surgery, the safety of cosmetic surgery patients must be adequately trained to deal with all eventualities.
is paramount. The failure of a large number of providers National bodies need to be more rigorous in their
to participate in this study effectively means they enforcement of these standards.
are not complying with the expectations of the CQC
or professional regulators, and hence are not being The report questions the care given to vulnerable
adequately regulated. There needs to be a change in patients. There should be more availability of trained
statute to ensure robust regulation of cosmetic surgery psychologists to assess patients who seek surgery on
for the safety of patients. At present, there is a part of the basis of a personal and subjective intolerance of their
the sector that gives the impression of being a cottage own appearance.
industry – unregulated and too small and disparate to
ensure best possible patient care. Too many sites appear Voluntary codes of conduct with regard to advertising
to be offering procedures that they perform infrequently. are insufficient to regulate unscrupulous advertising
Concentrating expertise and experience in fewer centres that could take advantage of the vulnerable patient. The
is recognised to improve outcome. solution to this rests with the government.
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There are some good signs on the horizon. There is a should recognise that the findings of this report create
cadre of providers which are able to demonstrate that a challenge for national regulation. There should be
they are delivering high quality cosmetic care, however specific guidance to cosmetic surgeons in a public
the regulators do not appear to have grasped the nettle format that is able to empower patients and protect
despite the Healthcare Commission and DH reports to good clinicians.
the Chief CMO. The effect of this failure of regulation is
that it is difficult for patients to be assured that they are On the face of it cosmetic surgery providers could do
receiving an appropriate level of care, when they decide better.
to seek treatment from a particular provider. The CQC
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References
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uks-largest-ever-breast-augmentation-survey uk/_db/_documents/Guidance_on_applying_for_
2. Office of Public Sector Information Part of the registration_Independent_private_and_voluntary_
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Hospitals etc 2000;14:1-3. http://www.opsi.gov. 10. Health Care Inspectorate Wales: Our Role. http://
uk/acts/acts2000/ukpga_20000014_en_1 www.hiw.org.uk/page.cfm?orgid=477&pid=13328
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Surgery in England: Report for the Chief Medical Authority: Who we are. http://www.rqia.org.uk/
Officer Sir Liam Donaldson. 2005. http://www.cqc. about_us/who_we_are.cfm
org.uk/_db/_documents/04013719.pdf 12. The Scottish Commission for the Regulation of Care:
4. Department of Health: Expert Group on the What we do. http://www.carecommission.com/
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uk/prod_consum_dh/groups/dh_digitalassets/@dh/ 13. Committee of Advertising Practice. http://bcap.org.
@en/documents/digitalasset/dh_4102100.pdf uk/about-us.aspx
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DH_079543. 15. Personal communication: British Association of
6. Independent Health Care Advisory Services: Good Aesthetic Plastic Surgeons. BAAPS – Marketing &
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surgery and strategic approach to the delivery of the Cosmetic Procedures. June 2009. http://www.
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8. What do we mean by ‘cosmetic surgery’ and ‘non- 18. General Medical Council: Good Medical Practice
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19. The Medical News. Booming Australian 27. American Society of Plastic Surgeons: A review
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20. Armenian Medical Network. German Plastic for patients seeking cosmetic surgery. Plastic and
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postanaes02.pdf
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Appendices
Appendix 1 - Glossary of terms and Blepharoplasty - This is a cosmetic procedure used to
abbreviations remove excess skin from the either the upper or lower
eyelid.
Abdominoplasty, scar revision - This is an operation also Breast Augmentation/Reduction - Breast augmentation
known as a ‘tummy tuck’, it involves removing excess fat involves surgically inserting an artificial implant to
and skin in order to make the abdomen more firm. increase the size of the breast. Breast reduction involves
ALS - Advanced life support certificate. The holder has removing excess tissue to reduce the size of the breasts.
passed an ALS course, reaching the standard defined Brachioplasty - A brachioplasty, or arm lift, is a surgical
by the resuscitation council (UK). The certificate is procedure to remove loose skin and excess fat deposits
recognised Europe wide and lasts for 4 years. in the upper arm.
Ambient media - Advertisements that have the aim of Browlift - Also known as a forehead lift or browplasty, is
either drawing mass-attention in centralised locations a cosmetic surgery procedure used to elevate a drooping
or that directly interact with consumers during normal eyebrow that may obstruct vision and/or to remove the
everyday activities. E.g. projecting images on sides deep “worry” lines that run across the forehead.
of buildings or displaying advertisements on car-park Buttock lift/ implant - A surgical procedure that removes
receipts, supermarket trolleys etc. excess skin and fat from the buttocks, and/or the
ASGBI - Association of Surgeons of Great Britain and insertion of an implant may enhance the appearance, size
Ireland. This is a defined speciality association for and definition of gluteal muscles in the buttock area.
general surgery. Body Dysmorphic Disorder - Defined as a
AAGBI - The Association of Anaesthetists of Great preoccupation with one or more defects in one’s
Britain& Ireland. The association represents the aspiration appearance for which most people can hardly notice
of over 10,000 anaesthetists. or do not believe to be important. To fulfil the criteria
ASA - The Advertising Standards Authority (ASA) is the for diagnosis of body dysmorphic disorder, it must also
UK’s independent regulator of advertising across all cause significant distress or difficulty to the person.
media, including TV, internet, sales promotions and direct Body lift - A body lift is surgery performed to correct
marketing. excess loose and sagging skin. Surgical body lifting
BAAPS -The British Association of Aesthetic Plastic improves the shape and tone of the underlying tissue that
Surgeons supports fat and skin.
BACP - British Academy of Cosmetic Practice. An CAP - Committee of Advertising Practice
independent overarching academic body that holds Cheek implant - Also known as Malar augmentation,
a list of practitioners who comply with a number of uses implants, usually made of synthetic material, to
specific descriptors in relation to qualifications, training, make cheek bones more prominent
experience and professional registration.
BAPRAS - British Association of Plastic, Reconstructive
and Aesthetic Surgeons.
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Clinic - This refers to an establishment (employing >3 Gynaecomastia - gynaecomastia is a common
cosmetic surgeons on a sessional basis) that carries out condition in teenage boys where firm tender breast
cosmetic surgery on site (although they may additionally tissue grows under the nipples. It is usually caused by
refer patients to other large hospitals for certain surgical an in balance if hormones during puberty and usually
procedures).Cosmetic surgery is the only service offered disappears in a couple of years.
by clinics, which may have overnight beds or cater only Hair transplant - A surgical technique that involves
for out-patients. moving skin containing hair follicles from one part of
CMO - Chief Medical Officer the body (the donor site) to bald or balding parts (the
Cosmetic surgery - For the purpose of this study the recipient site).
definition of cosmetic surgery “Operations that revise HIW – Health Inspectorate of Wales- the independent
or change the appearance, colour, texture, structure or inspectorate and regulator of all health care in Wales.
position of the bodily features to achieve what patients IHAS - Independent Healthcare Advisory Services
perceive to be desirable” was employed. Reconstructive - a representative organisation for the independent
plastic surgery (e.g. breast reconstruction after cancer) healthcare sector. A member of the Trade Association
or bariatric surgery was not included. Non-surgical Forum, IHAS exists to share innovation, knowledge and
procedures such as botox R(copyright), fillers, chemical expertise for the common good.
peels. dermabrasion, were also excluded. Independent hospital - This refers to a large facility
CQC -The Care Quality Commission is the regulatory (employing more than 3 cosmetic surgeons on a
body for health care in England. sessional basis) that is privately (or charitably) funded.
Data Protection Act - The Data Protection Act 1998 These sites offer a range of clinical services of which
places obligations on organisations or individuals who cosmetic surgery is but one. These sites may have
record and use personal data, and must follow sound overnight beds for in-patients or only day-beds, but
and proper practices (defined in the data protection cosmetic surgery would be carried out on site. These
principles). The Act defines eight principles of good organisations would normally oversee the patient
practice in relation to the storing, processing or managing throughout the patient pathway from initial consultation
of personal data, and requires all organisations to comply to post surgical aftercare. However they may also
with these principles. receive referrals from other organisations and only be
DH - Department of Health responsible for the surgery itself.
Direct mailing - Targeted advertisement messages are Individual cosmetic surgeon - This refers to a surgeon
sent directly to consumers usually in the form of a letter who acts independently from any other organisation
in the mail. and conducts consultations for surgery at a location
ED - Emergency Department geographically or administratively separate. He/She is
Facelift - Also called rhytidectomy, facelift is a plastic paid by the patient for their surgery and is responsible
surgery procedure used to remove facial wrinkles, for the patient’s care throughout the patient pathway.
sagging skin, fat deposits, or other visible signs of aging Initial consultation - For the purposes of this study,
for cosmetic purposes. the ‘initial consultation’ refers to the appointment with
Foreskin restoration - is the process of expanding the a member of staff within the organisation during which
residual skin on the penis, via surgical or non-surgical the patient first agrees to undergo a surgical procedure
methods, to create the appearance of a natural foreskin. and/or pays for, or commits to paying for this to take
GA - General anaesthetic place.
GMC - General Medical Council IP/OP - In patient / Out patient
GP - General Practitioner ISTC - Independent Sector Treatment Centre
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LA - Local Anaesthetic Referral Service (UK & Abroad) - This is an organisation
Labiaplasty - A surgical procedure to reshape the inner that organises cosmetic surgical operations. They act as a
lips of the vagina. broker, not carrying out any surgery but refer patients for
Laser liposuction - A method of liposuction that utilizes a surgery that is carried out elsewhere. The consultation may
laser during surgery to assist in unwanted fat removal. or may not take place on site, but a commission is usually
Level 2 care - Level 2 care or a high dependency unit charged. A referral service may organise cosmetic surgery
(HDU) is an area for patients who require more intensive in the UK or abroad.
observation, treatment and nursing care than can be Rhinoplasty - Aesthetic surgery of the nose where
provided on a general ward. It would not normally accept cartilage and bone are reshaped and reconstructed;
patients requiring mechanical ventilation, but could excess bone or cartilage may be removed.
manage those receiving invasive monitoring. RMO - Resident Medical Officer
Level 3 care - Level 3 care or an intensive care unit (ICU) RQIA - Regulation and Quality Improvement Authority
is an area to which patients are admitted for treatment (Northern Ireland)- the independent body responsible for
of actual or impending organ failure, especially when monitoring and inspecting the availability and quality of
mechanical ventilation is necessary. health and social care services in Northern Ireland, and
MACS facelift - Minimal Access Cranial Suspension encouraging improvements in the quality of those services
facelift or minilift. A successor to the traditional facelift. SASM - Scottish Audit of Surgical Mortality – SASM
MAC meetings- meetings of the Medical Advisory identifies all deaths that occur in Scottish hospitals under
Committee the care of a surgeon, whether an operation has taken
Mastopexy - Plastic surgery in which the breasts are lifted place or not. SASM forms are completed by the relevant
or reshaped. Surgeon and where appropriate Anaesthetist. The forms
MDT – Multi-disciplinary team then undergo a peer review process carried out by virtually
Necklift - Plastic surgery to remove facial wrinkles, every practising clinician within the audited specialties on
sagging skin, fat deposits, or other visible signs of aging behalf of their colleagues.
for cosmetic purposes. SCRC - were set up in April 2002 under the Regulation
NHS hospital - A hospital that is funded by the National of Care (Scotland) Act 2001 to regulate all adult, child
Health Service (even if certain aspects of care are and independent healthcare services in Scotland. We
independent). make sure that care service providers meet the Scottish
Non-Surgical Treatment Centre - This is a facility that Government’s National Care Standards and work to
mainly carried out non-surgical cosmetic procedures, improve the quality of care.
but may provide consultations for cosmetic surgical Small clinic - This refers to a small establishment
procedures. (employing 1-3 cosmetic surgeons on a sessional
Penis enlargement - There are two penis enlargement basis)that carries out cosmetic surgery on site (although
procedures: enlargement phalloplasty (increasing penis they may additionally refer patients to other large hospitals
length) and girth enlargement (increasing penis width). for certain surgical procedures). Cosmetic surgery is the
Pinnaplasty - Also known as otoplasty, a surgical only service offered by small clinics, which may have
procedure done to correct misshaped or protruding ears. overnight beds or cater only for out patients.
RCGP - Royal College of General Practitioners - the Specialist nurse practitioner - A registered nurse (RN)
professional membership body for family doctors in the UK who has completed an advanced training program in a
and abroad. We are committed to improving patient care, medical specialty. A specialist nurse practitioner may
clinical standards and GP training. function as a primary direct provider of health care and
prescribe medications.
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Thigh lift - A thigh lift can be performed to tighten sagging Appendix 3 - Corporate structure and role
muscles and remove excess skin in the thigh area. of NCEPOD
Thread/suture facelift - Minimally-invasive facelift
procedure involving the insertion of fine threads (sutures) The National Confidential Enquiry into Patient Outcome
through small incisions into deeper tissues. The threads and Death (NCEPOD) is an independent body to which
are attached to soft tissues and are pulled upwards to a corporate commitment has been made by the Medical
tighten the deep tissues and Surgical Colleges, Associations and Faculties related
Vaginoplasty - is a plastic surgery procedure used to to its area of activity. Each of these bodies nominates
construct or reconstruct a vaginal canal and mucous members on to NCEPOD’s Steering Group.
membrane.
The role of NCEPOD
Appendix 2 - Web-listings used to identify sites The role of NCEPOD is to describe the gap between the
providing cosmetic surgery care that should be delivered and what actually happens
on the ground. In some ways it is a glorious anachronism:
• Yell.com an exercise by the professions themselves to criticise the
• EEZE Business care that they deliver in the cause of improving the quality
• Consulting Rooms of the Service.
• BAAPS
• Hotfrog.co.uk The process is simple but effective. We begin with an
• Private Healthcare.com idea. Subjects can be suggested by anyone, but most
• Skinlaser directory come from the professional associations. It is measure of
• Harley Street guide.co.uk how deeply the medical profession are committed to the
• Laserlipo.co.uk improvement of their service that they should be voluble
• Cosmetic Surgery and Beauty Guide and enthusiastic about having the care that they deliver
• Zettai.net assessed and criticised by their peers.
• Revahealth.com
• Google We have far more proposals than we can carry out and
• Cosmeticsurgeon.co.uk each year studies are chosen by competitive secret ballot
• Cosmetic Surgery London of the NCEPOD Steering Group, after what is often a lively
• Cosmetic Health.net and partisan debate. In November 2007, when Parenteral
Nutrition (PN) was chosen with Surgery in the Elderly
which we will publish later this year, there were a further
12 disappointed studies.
Having gained Steering Group approval, the staff and
co-ordinators together with an expert group work up the
study design so as to get the raw material that they think
they will need to explore the quality of care. They design
the study and the questionnaires.
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Trustees Steering Group as at 16th September 2010
Mr Bertie Leigh - Chairman Dr R Birks Association of Anaesthetists of
Professor G T Layer - Honorary Treasurer Great Britain and Ireland
Professor M Britton Mr T Bates Association of Surgeons of
Professor J H Shepherd Great Britain & Ireland
Dr D Justins Mr J Wardrope College of Emergency Medicine
Professor L Regan Dr S Bridgman Faculty of Public Health
Professor R Endacott Medicine
Professor R Mahajan Royal College of Anaesthetists
Company Secretary - Dr M Mason Dr A Batchelor Royal College of Anaesthetists
Dr B Ellis Royal College of General
Clinical Co-ordinators Practitioners
Ms M McElligott Royal College of Nursing
The Steering Group appoint a Lead Clinical Co-ordinator Dr T Falconer Royal College of Obstetricians
for a defined tenure. In addition there are seven Clinical and Gynaecologists
Co-ordinators who work on each study. All Co-ordinators Mrs M Wishart Royal College of
are engaged in active academic/clinical practice (in the Ophthalmologists
NHS) during their term of office. Dr I Doughty Royal College of Paediatrics
and Child Health
Lead Clinical Co-ordinator Dr G Findlay Dr R Dowdle Royal College of Physicians
(Intensive Care) Professor T Hendra Royal College of Physicians
Clinical Co-ordinators Dr M Clements Royal College of Physicians
Dr J A D Stewart (Medicine) Dr S McPherson Royal College of Radiologists
Dr D G Mason (Anaesthesia) Mr B Rees Royal College of Surgeons of
Dr K Wilkinson (Anaesthesia) England
Dr A P L Goodwin (Anaesthesia) Mr M Parker Royal College of Surgeons of
Professor S B Lucas (Pathology) England
Mr I C Martin (Surgery) Mr D Mitchell Faculty of Dental Surgery, Royal
Professor M J Gough (Surgery) College of Surgeons of England
Dr M Osborn Royal College of Pathologists
Ms S Panizzo Patient Representative
Mrs M Wang Patient Representative
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Observers Appendix 4 - Supporting organisations
Ms R Brown National Patient Safety Agency The organisations that provided funding to cover the cost
Mrs C Miles Institute of Healthcare of this study:
Management National Patient Safety Agency on behalf of the
Dr R Hunter Coroners’ Society of England Department of Health in England and the Welsh Assembly
and Wales Government
Dr N Pace Scottish Audit of Surgical Department of Health, Social Services and Public Safety
Mortality (Northern Ireland)
Professor P Littlejohns National Institute for Health and Aspen Healthcare Ltd
Clinical Excellence BMI Healthcare
BUPA Cromwell
NCEPOD is a company, limited by guarantee (Company Covenant Healthcare Ltd
number: 3019382) and a registered charity (Charity East Kent Medical Services Ltd
number: 1075588), managed by Trustees. Fairfield Independent Hospital
HCA International
Hospital of St John and St Elizabeth
Isle of Man Health and Social Security Department
King Edward VII’s Hospital Sister Agnes
Netcare Healthcare UK Ltd
New Victoria Hospital
Nuffield Health
Ramsay Health Care UK
Spire Health Care
St Anthony’s Hospital
St Joseph’s Hospital
States of Guernsey Board of Health
States of Jersey, Health and Social Services
The Benenden Hospital Trust
The Horder Centre
The Hospital Management Trust
The London Clinic
The London Oncology Clinic
Ulster Independent Clinic
DISCLAIMER
This work was undertaken by NCEPOD, which received funding for this report from the National Patient
Safety Agency. The views expressed in this publication are those of the authors and not necessarily
those of the Agency.
60
Published September 2010
by the National Confidential Enquiry
into Patient Outcome and Death
4-8 Maple Street
London
W1T 5HD
T 020 76313444
F 020 76314443
E info@ncepod.org.uk
w www.ncepod.org.uk
A company limited by guarantee Company no. 3019382
Registered charity no. 1075588
The NCEPOD report On the face of it, looked into the 3. Am I confident that those who are proposing to
provision of service of cosmetic surgery, not at the undertake this operation fully understand the
quality of care of individual patients; however, as a matter emotional needs that have brought me to this
of general interest, NCEPOD and our advisors have decision?
looked at what the report means for those that may be
considering cosmetic surgery. Note what the NCEPOD report says about the value
of psychological evaluation on pages 22-23.
The Department of Health1, the BAAPS2 and the BAPRAS3
all have published checklists of questions that those 4. Have I received enough information about this
considering cosmetic surgery should ask of their potential procedure, including any possible risks, well before
provider. On the basis of the NCEPOD report, On the making the decision to undergo surgery?
face of it, NCEPOD suggests that patients considering
cosmetic surgery should also ask the following questions Note: The process of gaining information about what
of themselves and of their cosmetic surgery provider:- is available for you and the decision that you should
opt to undergo this operation should be separated,
Group 1: Questions you should ask yourself so that you have a chance to consider
the advantages and disadvantages.
Cosmetic surgery is a personal choice. The only
indication for it is your own personal desire to change 5. Have I given written consent for the surgical
your appearance. We think you should ask yourself the procedure in two stages? the first at the time of the
following questions. consultation, and the second stage just before the
surgery – at least 2 weeks later?
1. Am I proposing to have this operation to remedy
something that I think really needs improving rather Note: The risks and other disadvantages of this sort
than because someone else has told me I need it? of surgery should be spelled out well before you take
your decision, you need to make preparations
Note: As the BAAPS website points out, the real to be off work and generally become emotionally
expert on your appearance and any concerns you committed to the decision you have taken. As
may have is you. You do not need advice from a the BAPRAS website puts it, “cool off before you
nurse or surgeon about what is wrong with your commit.”
appearance.
6. Am I confident that I have been given enough time
2. Am I in the right frame of mind to be undergoing a for reflection or have I been hurried into a decision or
cosmetic surgery operation? offered any financial incentive to have the procedure
done soon?
Note the BAAPS website says you should avoiding
surgery if you have just undergone a major life event, Note: The BAAPS website advises you to beware
such as moving house, changing job, bereavement, of what appear to be “free” consultations and any
break up of a relationship or the arrival of children. financial arrangements that may appear to influence
your judgement or lock you into a decision.
Group 2: Questions you could ask the Clinic 12. Who will deliver the anaesthesia for my operation,
and are they on the specialist register as an
These questions may seem pointed and direct, but they anaesthetist?
are all requests for information that we think should be
made available to people who are proposing to undergo 13. Is the hospital/ clinic registered with the CQC? If so:
surgery at the hands of the clinic/hospital. If the Clinic/ 7.1 Is the Regulated Activity the Performance of
hospital does not welcome the opportunity to answer Surgical Procedures?
them you may be in the wrong place. 7.2 When was the last inspection? And
7.3 What was the outcome?
7. Is there a financial penalty if I change my mind about
having surgery? If yes, up to which date can I change Note: the CQC is the official government regulator of
my mind without a financial penalty? these clinics, but it regulates a number of other sorts
of healthcare establishments as well.
8. Has the surgeon performed the same operation I
am to undergo with the same team in the clinic or 14. Will I be provided with guidelines on what to do
hospital where I am to have my operation regularly in if I become ill after going home, and is there an
the last 12 months? emergency 24 hour telephone help-line to call?
Note what the NCEPOD report says about infrequent 15. Which hospital will I go to if I become ill after going
surgery on page 29. home?
9. How many of those patients have complained to you 16. If there is a problem during or after my operation and
about the quality of their result or any other aspect of I need a greater level / dependency of care than can
their experience? be provided at this hospital, where will I go?
10. Does the surgeon hold an NHS consultant Note what the NCEPOD report states on this subject
appointment? If yes, in which hospital is this? And in of post operative support if things do not go well on
which specialty is the surgeon on the GMC specialist pages 32-5
register?
Note: Consider the sort of operation you are References
proposing to undergo and the relevance of the 1. The Department of Health: http://www.dh.gov.uk/
training that your surgeon has received. The range prod_consum_dh/groups/dh_digitalassets/@dh/@en/
of surgeons doing this work is described on pages documents/digitalasset/dh_4138410.pdf
30-31.The views of BAAPS and BAPRAS are set out 2. BAAPS: http://www.baaps.org.uk/safety-in-surgery/
on their websites. consumer-safety-guidelines
3. BAPRAS http://www.bapras.org.uk/guide.
11. Is the surgeon a member of an appropriate asp?id=135
specialist association e.g. ASGBI,BAAPS, BAOMS,
BAORLHNS, or BAPRAS?
